Scribd
Upload
19 views

Quotation Request Form

This document is an application form for a group medical insurance quotation. It requests personal details of applicants, information on eligibility and premium payment, previous claims experience, and a list of members to be covered. The applicant must declare that the information provided is true and complete, and consents to the data being used for insurance purposes. The form collects names, dates of birth, nationalities, professions, ID numbers and other data on multiple members to provide a quote for group medical coverage.

Uploaded by

Viral Patel
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
19 views

Quotation Request Form

This document is an application form for a group medical insurance quotation. It requests personal details of applicants, information on eligibility and premium payment, previous claims experience, and a list of members to be covered. The applicant must declare that the information provided is true and complete, and consents to the data being used for insurance purposes. The form collects names, dates of birth, nationalities, professions, ID numbers and other data on multiple members to provide a quote for group medical coverage.

Uploaded by

Viral Patel
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 3

-1-

APPLICATION FORM & QUOTATION REQUEST

1- Your Personal Details

Name: ...
Nationality: ..
Dept/ Section: .
Designation: .
Office Tel No: . Mobile No:
Fax No: Residence Tel No: ..
Bank Details:
Account No: .
Address: ..
...
..
..
..
Contact Name: ..
Position in Company:
Telephone: .
Fax: .
Email: ..

2- Eligibility/ Premium Payment

Employee family status:


Family
Single
Parent
Couple
.

Will the insurance apply to employees only?


Yes
No
..

Are the employees dependants to be covered?


Yes
No
Other

..

Will the Company be paying the premium for:


Employees only?
Yes
No

Employees and dependants? Yes

Other

No

please specify:

.
.
3-Premium Payment Frequency
Please indicate your preferred method of payment:

Annually
6-monthly

(5% administration charge applies)


..

4-Previous Claims Experience


a) Have you previously been insured for medical
benefits?
Yes
No
.
If yes, please give names(s) of previous insurers here and
attach previous benefits and renewal date details:

APPLICATION FORM & QUOTATION REQUEST

-2-

b) Please provide the following information (if available)


Year

Total membership
covered

Premium
paid

Number of
Claims

....

Amount
of
Claims

c) Please provide separate details of any claims which individually exceed USD 10,000:

6- Details of Membership:
NAME

SEX

DOB

NATIONALITY

....

...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
..........

PROFESSION/
RELATION

STATE OF
QATAR ID #

....

7- Data Protection:
The Company complies with the principle of data protection and declared for the safekeeping of
data and will only use the information contained on this application for the purposes of advising
on healthcare and related products.

APPLICATION FORM & QUOTATION REQUEST

-3-

9- Declaration by Employee or Authorized Representative:


I declare that to the best of our knowledge and
belief the information given herein is true and
complete.
Name:

Signature:

Date:
(DD/MM/YY)

APPLICATION FORM & QUOTATION REQUEST

You might also like