health

International Protection Document



Subscriber data















Document data



Beneficiary data

Civil ID number
                
First name in English
                
English last name
                
Reltionship
                
minor




Are you in good health?
Have you ever complained of any disease?
Have you ever been involved in an accident, injury or any operation?
Have you received or are currently taking any treatment for any disease?
Do you have alcohol or any drugs?
Do you smoke cigarettes or tobacco?




I acknowledge that the data and answers in this form are correct and complete to the best of my knowledge and belief and agree that this statement along with any statement besides the medical examination should be the basis of the contract between me and the company. If any incorrect statement is made in it, or if there is any material concealment, the insurance contract will be null and void and all amounts paid in this respect shall be confiscated by the company. I fully understand that the company will not be at risk for my life until issuing an official letter of acceptance by the company and paying the premium owed to me by.