ENROLLMENT FORM

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ICBF - LIFE INSURANCE SCHEME
ENROLLMENT FORM

INSURED DETAILS

Please attach a copy of QID and Passport of the insured member
Premium QAR 125/- (for two years)

NOMINEE DETAILS

I hereby declare that the information I have provided is complete, truthful & correct and I am currently active & not
undergone any hospitalization in the last 3 months. I agree to the terms and conditions of the Policy. I also hereby authorize
to disburse the policy amount to the nominee mentioned above in case of any incident and indemnify ICBF from any legal
responsibility whatsoever.

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