Group Personal Accident Insurance

Name of Insured/Principal/Correspondence*
Address of Insured/Principal/Correspondence*
Email*
Mobile*
Industry Type*
Age Band*
No.of Lives*
Total Sum Insured*
Risk Category *
Terrorism damage*
Medical Extension *
Weekly compensation*
Coverages (if yes) please select only one option*
Please download file, input data and upload for premium*
Attachment*