Personal accident

The policy provides compensation in the event of Death or Permanent Disability, whether total or partial, caused by an Accident. Also, The Policy may be extended to cover the reimbursement of Medical Expenses up to a previously fixed sum insured and incurred as a result of an Accident.

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Your Resident Country *

Your Resident Currency *

Corporate Information

Company Name *

Activity Of The Company *

Title*

First Name*

Last Name*

Occupation *

Mobile *

Email *

Address *

Website

Personal Accident

Number of Employees

The insured persons activity/positions

Insured Age

From

Scope of cover

Scope of work

Cover Death

Cover Permanent Total Disablement

Do you wish to be covered against Temporary Total Disablement ?

Yes

Would you like cover medical expenses following an accident ?

Yes

The limit per accident ( Not exceed 25% of sum insured )

Remarks

We hereby acknowledge and confirm that all the submitted data above are correct and We did not hide any information related to the risk to be insured. And We authorize Brokerage Insurance Brokerage in executing this insurance request with the concerned insurance company and facilitate the policy issuance, renewals and claims follow-up and communicate specific information about us and our account to third parties if needed, in accordance with the privacy policy. We also accept that this insurance application and approval be the basis of the contract and an integral part of the insurance policy.