|
Name & Surname*
|
|
|
ID card number*
|
|
|
Date of birth*
|
|
|
Address*
|
|
|
Phone number*
|
|
|
Mobile number*
|
|
|
Email Address*
|
|
|
Main Occupation*
|
|
|
Secondary Occupation*
|
|
|
Your hobbies, habits & pastimes*
|
|
|
What kind of insurance do you require?
|
|
Do you require cover on*
|
- Occupational basis
- 24 hour basis |
|
Do you wish cover to operate*
|
- Maltese Islands
- Worldwide |
|
Do you wish to cover any other persons apart from yourself?
|
|
|
Name & Surname
|
Date of Birth
|
|
Relationship
|
Occupation
|
|
Name & Surname
|
Date of Birth
|
|
Relationship
|
Occupation
|
|
Name & Surname
|
Date of Birth
|
|
Relationship
|
Occupation
|
|
Name & Surname
|
Date of Birth
|
|
Relationship
|
Occupation
|
|
Benefits to be insured
|
|
Benefit
|
Sum required (in euro) |
|
Death / Full Payment disablement*
|
€ |
|
Temporary total disablement
|
€ |
|
Medical expenses
|
€ |
|
Have you or any other person proposing to be insured
|
|
Been involved in any accidents during the past five years?*
|
|
|
Ever had a proposal for insurance declined, renewal refused, cover terminated, increased premium required or special conditions imposed by any insurer?
|
|
|
Ever been convicted of (or charged but not yet tried with) arson, or any offence involving dishonesty of any kind?
|
|
| |
|