ENROLLMENT FORM

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Damaan Islamic Insurance Company

ICBF - LIFE INSURANCE SCHEME
ENROLLMENT FORM

INSURED DETAILS

*Name

Date of Birth

QID No

Passport No.

Mobile No.

Gender

Male Female

Nationality

Association/Company Name

Permanent Address & Contact No.

Notes

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

ICBF

NOMINEE DETAILS

Nominee Name

Relation

Nominee Permanent Address

Nominee Phone No

Nominee Email

DECLARATION

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.

Name

Date

Signature

Fields with (*) are compulsory.