Personal Accident Insurancee 1 Personal Details 2 Personal Accident Details Name* First Last Email* Telephone (Landline)*Mobile*Address* Emirates / City*Select a CityAbu DhabiAjmanDubaiFujairahRas al-KhaimahSharjahUmm al-QaiwainPO BoxPeriod of Insurance requiredFrom*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920To*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Nature of Business Number of Employees*Sum Insured Option Repatriation Expense CoverYesNoMedical ExpensesYesNoDisappearance coverYesNoAre your involved in any offshore activityYesNoIf yes, with whom Do you have a Current PolicyYesNoIf yes, with whomHave you suffered any losses in the past years (Claims experience)YesNoif Yes, then claim history for last 3 yearsHas any insurer ever declined to insure youYesNoDocuments Required