Addition Form
Addition Form
2. CHANGE INFORMATION
Reason for ADDING Dependents (Please Select)
Marriage
Birth
Others (Pls. Explain) With Effect From D D M M Y Y Y
3. DETAILS OF DEPENDANT(S)
[Please note children will be eligible for cover from the age of 61 Days up to 21 years (Unmarried Only). Children above 21
years but below 25 years may be accepted on proof of fulltime schooling.]
No Full Name Date of Birth Gender Relation
1 D D M M Y Y Y Y M F
2 D D M M Y Y Y Y M F
3 D D M M Y Y Y Y M F
4 D D M M Y Y Y Y M F
5 D D M M Y Y Y Y M F
6 D D M M Y Y Y Y M F
7 D D M M Y Y Y Y M F
8 D D M M Y Y Y Y M F
9 D D M M Y Y Y Y M F
10 D D M M Y Y Y Y M F
Please Provide Additional Information while ADDING Spouse:
Full Name
Nationality ID/Passport No
Mobile Phone Email ID
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AMANAH INSURANCE
4. CONFIDENAMANAHL MEDICAL HISTORY
State whether any of your dependants have ever been treated or are currently receiving treatment, or expect to
receive treatment for any of the following illnesses including but not limited to:
Please indicate YES or NO in the box below
Question Spouse Dependents
1 Blood disorders. e.g. anemia, bleeding disorders, leukemia
If you answered YES to any of the questions (No. 01-11) above, please write details below:
Q. Consulting
Name of Person Date Diagnosis Treatment
NO. Doctor
(If the space provided is insufficient, please attach additional information to this application.)
N.B: Any misrepresentation or non-disclosure of material or factual information will render all benefits granted by
Amanah Insurance null and void. In addition, any claims payment made due to such actions will be recoverable
from the policy holder.
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AMANAH INSURANCE
4. DECLARATION
I, the undersigned principal applicant member Warrant that the contents of this application and any other documents which
may be required in support thereof are true, correct and complete to the best of my knowledge and belief. This addition form
is the part of my application form which I submitted earlier.
______/______/________ ________________________________
Date Signature of Principal Member
THIS SECTION FILLED UP BY THE EMPLOYER/ORGANIZATION
Stamp of Employer (Mandatory) Signature of Authorized Person of Employer
_____________________________________________
___/____/______ _________________________________________
(If the space provided is insufficient, please attach additional page to this application.)
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