APPLICATION FORM

Policy No. ______________________________Issue Date: ____________________________ Period of Insurance (Departure Date): From:_________________To:____________________ Particulars of Insured Name: _______________________________________________________________________ Date of Birth: _________________________________________________________(dd/mm/yy) Travel Destination: ________________________ Purpose of Visit: ________________________ CNIC: ________________________________________________________________________ Passport Number: ______________________________________________________________ Address: ________________________________________________________________ ________________________________________________________________ Phone No: ________________________________________________________________ Spouse Name (If accompanying): ___________________________D.O.B:_________________ Childrens Name & D.O.B. (If accompanying): 1. ____________________________________ 2. ____________________________________ 3. ____________________________________ 4. ____________________________________ PLAN OPTED:________________________ Premium Payable: Rs.____________________ Name of Beneficiary & Relationship with the Insured:_____________________________________________________ Geographical Coverage: Worldwide Jurisdiction: Pakistan Declaration I hereby declare and affirm that the information provided in the Application From is true to the best of my knowledge and I am sound health. I am neither traveling against the advice of my medical practitioner nor am I traveling with purpose of making a claim under this policy. Please see the policy wording for a complete

description of its scope and limitations of coverage. ______________________________ ______________________________

Authorized Signature Insureds Signature On Behalf of

Adamjee Insurance Company Limited