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Personal Accident Insurance
* is mandatory
Person to be Insured
*
Title
Mr.
Prof.
Dr.
Ms.
Mrs.
*
Name in full
*
Address
Telephone
*
NIC / Passport No
*
Date of Birth
Year
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
*
Class of Profession or Occupation
Please select the class
Class 1
Class 2
Class 3
Class 4
Please click here for more details of Profession or Occupation
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Beneficiary to whom the proceeds of this policy should be paid in the event of death
*
Title
Mr.
Prof.
Dr.
Ms.
Mrs.
*
Name in full
Address
Relationship to the insured person
NIC No
-----------------------------------------------------------------------------------------------------------------
*
Period of insurance From
*
Sum Insured LKR
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Benefits Required (State Yes or No)
Event
Benefit
*
Death
100%
Yes
No
Permanent Disablement
As per our standard Schedule (To see Schedule of permanent disabilities benefit
click here
)
Yes
No
Motor cycling (As rider or passenger)
Yes
No
Strike,Riots,Civil,Commotions
Yes
No
Terrorism
Yes
No
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Other Information
*
Have you been been declined deferred or accepted on special terms for life, accident or sickness insurance or has any insure cancelled or declined to renew your policy for accident or sickness or any claim made through any other insurance company ?
Yes
No
*
Are there any circumvent connected to your occupation, pastime or habits of life that render you particularly liable to injury or sickness?
Yes
No
*
Do you intend to undertake air travel other than as a fare paying passenger ?
Yes
No
*
Have you any physical defects or infirmity or sickness or disease of any kind ?
Yes
No
Please contact Head Office on
011-4724422
, if any of the above answer is "YES"
-----------------------------------------------------------------------------------------------------------------
(LKR.)
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