INDIVIDUAL TERM ASSURANCE PROPOSAL FORM

BML INSURANCE ‫އނޑވޖއލ ޓރމ އޝއރނސއށ އދ ފމ‬

Proposal no. Policy no.

Individual Company National ID Card

     

Occupation: Nature of Business: Work Permit Passport

      

ID No.
       

Date of Birth: Male Female Reg No.

  D D M M Y Y Y Y    

Permanent Address (as in ID card): Contact Name:

       

Current Address: Nationality:

‫މހރ އޅ އޑރސ‬ 

House/Building name: Contact No:

     

Road: District: Email:

  
Postal Code: Atoll,Isand: Fax:
    

Marital Status: Single Married Divorced Widow

   
 

Nature of Work (Please tick whichever is applicable) (Wvwscawj wgwhWf Luwgnwr iawgiawb ELgu cnk
u wtiawb WviawgIrit) ctwkcawswm Wrk
u Wdwa

Engaged in professional, administrative, managerial, clerical and non-manual occupations

             

Engaged in work of supervisory nature but not involved in manual labour

        

Engaged either occasionally or generally in manual work which involves the use of tools or machinery
          

cscnwrwax
u cnia Wvcnn
u Eb

Plan of assurance : WP/NP With effect from:

       

Sum assured: Term: Premium amount:

      ‫ ފއސގ‬

Frequency of premium payments: monthly quarterly half yearly yearly single

          
    

Mode of premium payment: Cash Cheque Bank order Salary deduction Internet banking
       
    

1-6
Family History u WmUlAuwm egWliaWa
t

Have you previously made any life proposal with Allied? Yes No
       

Family history Age if living State of health Age at death Cause of death
        

Father


Mother
‫މނމ‬

Brothers
  ‫އއބނޑ‬

Sisters
  ‫އއބނޑ‬

Personal History u WmUlAuwm wscaWH egt

t u Wrwf Everk
u rwax
u cnia

Height: cm Weight: kg How many cigarrettes do you smoke daily?

          

Name and address(Clinic/Hospital) of your usual medical attendant:

     

Has been attendant for years Date of last visit:

        
 

Reason for last visit:

    

a. In addition to the visit mentioned above have you consulted any other medical practitioner (please give name) during Yes No
              
    
If Yes give full particulars: 2-2
   

b. Have you ever attended hospital for treatment, operation or investigation or had any x-ray? Yes No
             

If Yes give full particulars:

   

c. Have you ever suffered from any of the following?

       

1. Bronchitis, asthma or any other complaint of the lungs or respiratory system. Yes No
         

If Yes give full particulars:

   

2-6
 Yes No
b. Are you a beta Thalassaemia carrier?  

              

   

If Yes give full particulars:
   

3. Any form of nervous breakdown or depression or have you consulted a psychiatrist? Yes No
 
             

If Yes give full particulars:  

   

4. Unexplained recurrent or persistent fever or skin disorder? Yes No

 
       
If Yes give full particulars:
   

5. Unexplained persistent night sweats? Yes No

 
    

If Yes give full particulars:

   

6. Unexplained weight loss? Yes No

 
    

If Yes give full particulars:

   

7. Unexplained infections or swollen glands? Yes No

 
    

If Yes give full particulars:

   

8. Chronic recurrent diarrhea? Yes No

 
        

If Yes give full particulars:

   

9. Persistent cough? Yes No

 
    

If Yes give full particulars:

   

10. Hepatitis B, any sexually transmitted disease, including genital sores or discharges? Yes No
 
          

  

If Yes give full particulars:
   

3-6
 11. Stroke High or Low blood pressure? Yes No
 
       

If Yes give full particulars:

   

12. Are you suffering from Diabetes Mellitus? Yes No

 
   

If Yes give full particulars:

   

13. Are you suffering from any thyroid dysfunction? Yes No

 
    

If Yes give full particulars:

   

14. Cancer, growth or other malignancy? Yes No

 
       

If Yes give full particulars:

   

15. Any kidney or bladder disorder? Yes No

 
       

If Yes give full particulars:

   

16. Any disease or disorder of the eyes, ears, nose or throat? Yes No
 
          

If Yes give full particulars:

   

17. Dizziness, numbness or paralysis? Yes No

 
      

If Yes give full particulars:

   

18. Any illness or disease not mentioned above? Yes No

 
       
If Yes give full particulars:
   

d. Are you taking any medicine or drug or receiving any treatment? Yes No
 
        

If Yes give full particulars:

   

4-6
e. Has any Insurance company ever requested any additional premium or postponed or declined a Yes No
proposal for life assurance on your life?  
           
   
Do you have any intention or expectation?
      

Yes No
       

2. Of engaging in motor racing or other hazardous pursuits? Yes No

         

3. Of changing your occupation? Yes No

 
 

If Yes give full particulars:

   

f. Have you ever had or been advised to have a blood test for AIDS or an AIDS related condition? Yes No
 
          

If Yes give full particulars:

   

g. Have you ever been refused as blood donor? Yes No

 
        

If Yes give full particulars:

   

Yes No
 
       

If Yes give full particulars:

   

e. FOR FEMALES ONLY wscaWH cSwncnl

u wbnwk cnehcnwa .v
Yes No
1. Have you been menstruating regularly?   
 

Yes No
2. Have you had any miscarriage?    
 

Yes No
3. Are you pregnant now?  
 

Yes No
4. Have you suffered from any disease of breast, ovaries or uterus?
 
       

5. State date of last menstruation      
6. State date of last delivery    

If Yes give full particulars:

   

5-6
 cawtctWrwf Edea cSwmv
u caelibil Wsiawf egIsilop wtwvn
u Irwxifeneb

Name: Relationship:
  

ID No. Address:
  

cawtctWrwf Edea cSwmv

u caelibil Wsiawf egIsilop wtwvn
u Irwxifeneb

Name: Relationship:
  

ID No. Address:
  

DecIaration: I hereby declare that the above answers and statements are true, and that I have not withheld any information whatsoever regarding this proposal. I agree
that this Declaration and answers given above, together with those made by me to the medical examiner acting on behalf of the company shall form the basis of the
contract with the company. I hereby further declare that I agree that in the event the declaration shall contain any misstatement, misrepresentation, suppression and/
or fraud, the issuance of the policy shall not be nor deemed to be a waiver of such misstatement, misrepresentation, suppression and/or fraud. I hereby authorize any
hospital, surgeon, medical practitioner or clinic or other person who attended to me for any reason to disclose to the Insurance Company any and all information with

shall be considered as effective and valid as the original. I acknowledge that the liability of the Insurance Company does not commence until this proposal is accepted
by and premium paid to the Insurance Company.
                   
                  
                  
                   
                    
                  
     

Signature:  Date: 

To be completed and signed by the proposer (If other than life to be assured) (wmwn cnUn ctWrwf Wvwgcnwn cscnwrwax
u cnia) ctWrwf Wvcawrk
u iaos iawvcar
u fu muOf cscnwrwax
u cnia

Name: Relationship:
  
Contact No: Mobile No: Address:
     
Email: Sign: Date:
  

Documents required with the Proposal:

             

THIS INSURANCE WILL NOT BE IN FORCE UNTIL THE PROPOSAL HAS BEEN ACCEPTED BY THE COMPANY
      

6-6