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, declare, to the best of my knowledge, that I am in a good health, do not suffer from any disease and I am not undergoing
any medical treatment. 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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