ERECTION ALL RISKS

APPLICATION FORM INSURANCE

FOR SHIFA
INIDIVIDUAL/FAMILIES PLANS
Erection All Risks Insurance
Contractors’FORM
APPLICATION All Risks
FORInsurance
SHIFA
Proposal Form
1. POLICYHOLDER INIDIVIDUAL/FAMILIES
DETAILS PLANS
Proposal Form
Last name ......................................................................................................... First name ..................................................................................................

Title ADNIC is a Public Joint Stock Company incorporated

....................................................................................................................
1. POLICYHOLDER DETAILS
in the ...................................................................
Date of birth (dd/mm/yyyy) United Arab Emirates
by
ADNIC
Marital Law....................................................................................................
status No.
is (4) of 1972,
a Public Joint Stock and itCompany is governed Sexby the provisions
incorporated of theArab
Min the FUnited UAEEmirates
Federal
Last name ......................................................................................................... First name ..................................................................................................
Law
by Law
Occupation No. (6) of
No. (4)2007 of 1972, “Establishmentand it is governed of the Insurance
....................................................................................................... by (cm)
Height Authority
provisions&ofOrganization
the .................................. the (kg)
Weight of its
UAE................................
Federal
Title .................................................................................................................... Date of birth (dd/mm/yyyy) ...................................................................
Operations”,
Law
Monthly No.
gross salary with
(6) of Registration
2007 No. (1).
Less“Establishment
than AED 4,000/- of Greater
the Insurance Authority
than AED 4,000/- & Organization of its
Marital status .................................................................................................... Sex M F
Operations”,
Nationality
Occupation
with Registration
............................................................ Passport [Link].(1). .............................................
....................................................................................................... Emirate of visa issuance
Height (cm) .................................. ................................................
Weight (kg) ................................
Completing this form
Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-

Completing this form

Nationality ............................................................ Passport no. ............................................. Emirate of visa issuance ................................................
In order to apply for this insurance, please complete all parts of this proposal form and
Address .....................................................................................................................................................................................................................................
the annexures,
In order to apply if for
[Link] insurance, please complete all parts of this proposal form and
Town/City ......................................................................................................... Country/State ..........................................................................................
the annexures, if any.
Mobile number.....................................................................................................................................................................................................................................
Address ................................................................................................ Email ..........................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................
You must provide full, accurate, and true answers to all questions listed below. Material
Mobile number ................................................................................................ Email ..........................................................................................................
facts
You must which provide you know full, accurate, or oughtand to true know answers shouldtobe all fully
questions and listed accurately [Link]. Material
2. COMPANY
Failure to DETAILS
do so may result
(if applicable) in rejecting your claim and/or terminating the insurance
facts which you know or ought to know should be fully and accurately disclosed.
policy
Failurefromto doinception. so may result in rejecting your claim and/or terminating the insurance
Company name ........................................................................................................................................................................................................................
2. COMPANY DETAILS (if applicable)
policy from inception.
Address .....................................................................................................................................................................................................................................
Company name ........................................................................................................................................................................................................................
If you
Town/City .........................................................................................................
are in any doubt about what you should ..........................................................................................
disclose,
Country/State please do not hesitate
Address .....................................................................................................................................................................................................................................
Emailto..........................................................................................................................................................................................................................................
contact us. A material fact is one that wouldCountry/State influence our decision whether to offer
If you are in any doubt about what you should disclose, please do not hesitate
Town/City ......................................................................................................... ..........................................................................................

you
to insurance
contact
Email us. Aormaterial the terms factwhich is onewe that offer.
..........................................................................................................................................................................................................................................
would influence our decision whether to offer
you insurance or the terms which we offer.
3. DEPENDENTS TO BE INCLUDED IN THE PLAN
If the space provided is inadequate, please provide details using an additional
3. DEPENDENTS TO BE INCLUDED IN THE PLAN
information
Please
If enter
thethespacedetails sheet, signedis and
of all the dependents
provided to [Link] under this policy. This can include your legal spouse and your unmarried,
inadequate, please provide details using an additional
financially
Pleasedependent children
enter the details under
of all the age of to
the dependents [Link]
The place under
covered of residence of the
this policy. Thislegal spouseyour
can include and legal
the unmarried
spouse andfinancially dependent
your unmarried,
children
information sheet, signed and dated.
must bedependent
financially with the Policyholder
children underunless the
the age of Insurance company
18. The place approves
of residence of thethe other
legal arrangements.
spouse and the unmarried financially dependent
Your
childreninsurance does
must be with the not unless
Policyholder commence when
the Insurance you
company sign
approves thethe
otherproposal.
arrangements. Your cover will only
Height Weight Date of birth Emirate of
Last name First name Relation Sex
commence
Your Lastinsurance
name
once we have
doesFirstnotnamereviewed
commence the proposal
when you Sex
Relation
form and
(cm) confirmed cover
(kg) Date(d m - y)inEmirate
- birth
sign the proposal. Your cover will only
Height Weight of writing.
visa issuance
of
(cm) (kg) (d - m - y) visa issuance
M F / /
commence once we have reviewed the proposal M form
F and confirmed/ cover
/ in writing.
M F / /
Please keep a copy of this proposal form for your
M
record
F
along with any/ correspondence/
/
M F / /
information provided to us and policies/endorsements
Please keep a copy of this proposal form for your
M record
F that are issued to you
along with any/ correspondence/
/
M F / /
subsequently.
information provided to us and policies/endorsements
M F that are/ issued
/ to you
M F / /
M F / /
subsequently.
Policyholder is theisperson/company
Policyholder who
the person/company hashas
who thethe
right totoconfirm,
right confirm,alter
alter or
or renew thisinsurance
renew this insurancecover
coveronon behalf
behalf of the
of all all the insured
insured
members underunder
members the same policy,
the same andand
policy, who is responsible
who is responsiblefor
forthe
thepremium
premium payment againstinsurance
payment against insurance cover
cover under
under thisthis policy.
policy.

[Link] 839 Abu Dhabi - U.A.E. • Tel: +971(0) 2 4080100 • Fax: +971(0) 2 4080604 • [Link] • Toll free: 800 8040 • Email: info@[Link]
Public Shareholding Company established in 1972 with a paid up capital of AED (375)m, Registered at the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007.
[Link] 839 - Abu Dhabi, U.A.E. [Link] 8392 4080100
Tel: +971 (0) Abu Dhabi
Fax:-+971
U.A.E.
(0) 2•4080604
Tel: +971(0) 2 4080100••Toll
• [Link] Fax: +971(0)
free: ͧ˻!˯
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Public Shareholding Company established in 1972 with a paid up capital of AED (375)m, Registered at the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007.
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Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
Public Joint Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
ADNIC-COMU-02-PF05 1/4 1/10
1/4
 ERECTION ALL RISKS
APPLICATION FORM INSURANCE
FOR SHIFA
INIDIVIDUAL/FAMILIES PLANS

1. Proposal details APPLICATION FORM FOR SHIFA

INIDIVIDUAL/FAMILIES PLANS
1. POLICYHOLDER DETAILS
a. Name of the proposer (in full):
Last name ......................................................................................................... First name ..................................................................................................

Title ....................................................................................................................
1. POLICYHOLDER DETAILS Date of birth (dd/mm/yyyy) ...................................................................

Marital status .................................................................................................... Sex M F

Trading
Last name (if different from business name):
name ......................................................................................................... First name ..................................................................................................
Occupation ....................................................................................................... Height (cm) .................................. Weight (kg) ................................
Title .................................................................................................................... Date of birth (dd/mm/yyyy) ...................................................................
Physical address:
Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-
Marital status .................................................................................................... Sex M F
Postal
Nationality address:
............................................................ Contact person:
Passport no. ............................................. Emirate of visa issuance ................................................
Occupation ....................................................................................................... Height (cm) .................................. Weight (kg) ................................

Monthly gross salary

Telephone no.: Less than AED 4,000/- GreaterLandline:
than AED 4,000/-

Nationality ............................................................ Passport no. ............................................. Emirate of visa issuance ................................................

Mobile: Fax no:
Address .....................................................................................................................................................................................................................................
Email address:
Town/City ......................................................................................................... Country/State ..........................................................................................

[Link]
Mobile VAT .....................................................................................................................................................................................................................................
Tax
number Registration Number (if applicable):
................................................................................................ Email ..........................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................
c. Contract name:
Mobile number ................................................................................................ Email ..........................................................................................................

(If project consists

2. COMPANY DETAILS of several sections, specify sections(s) to be insured)
(if applicable)

Company name ........................................................................................................................................................................................................................

2. COMPANY DETAILS (if applicable)
Address .....................................................................................................................................................................................................................................
Company name ........................................................................................................................................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................
[Link] .....................................................................................................................................................................................................................................
Location of erection site:
..........................................................................................................................................................................................................................................
Email Town/City ......................................................................................................... Country/State ..........................................................................................
Country:
Email ..........................................................................................................................................................................................................................................

City, town, village:

3. DEPENDENTS TO BE INCLUDED IN THE PLAN
e. [Link]:
DEPENDENTS TO BE INCLUDED IN THE PLAN
Please enter the details of all the dependents to be covered under this policy. This can include your legal spouse and your unmarried,
Name
financially
Please and
enter theaddress:
dependent children
details under
of all the age of to
the dependents [Link]
The place under
covered of residence of the
this policy. Thislegal spouseyour
can include and legal
the unmarried
spouse andfinancially dependent
your unmarried,
children must be
financially with the Policyholder
dependent children underunless the
the age of Insurance company
18. The place approves
of residence of thethe other
legal arrangements.
spouse and the unmarried financially dependent
children must be with the Policyholder unless the Insurance company approves the other arrangements.
Height Weight Date of birth Emirate of
Last name First name Relation Sex
(cm)
Height (kg)
Weight Date(dof- birth
m - y) Emirate
visa issuance
of
f. MainLast
contractor(s):
name First name Relation Sex
(cm) (kg) (d - m - y) visa issuance
M F / /
Name(s) and address(es): M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
g. Subcontractor(s):
Policyholder is theisperson/company
Policyholder who
the person/company hashas
who the right
the righttotoconfirm,
confirm,alter
alter or renewthis
or renew thisinsurance
insurancecover
coveronon behalf
behalf of the
of all all the insured
insured
members underunder
members the same policy,
the same andand
policy, who is responsible
who is responsiblefor
forthe
thepremium
premium payment againstinsurance
payment against insurance cover
cover under
under thisthis policy.
policy.

Name(s) and address(es):

[Link] 839 - Abu Dhabi, U.A.E. Tel: +971 (0) 2 4080100 Fax: +971 (0) 2 4080604 • [Link] • Toll free: 800 8040 ͧ˻!˯
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[Link] 839 - Abu Dhabi, [Link] 839 AbuFax: Dhabi
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U.A.E. • Tel: +971(0) 2 4080100
U.A.E.2007
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Tel: +971 (0) 2 4080100 2 4080604 • [Link] • Fax:
• Toll free:+971(0)
800 80402 4080604 • [Link]
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Public Shareholding Company established
establishedinin1972 withPaid
a paid up capital
of AEDof570,000,000
AED (375)m,andRegistered
Public Joint2007
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Stock Company 1972 with up Capital at the
licensed by the zo
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Insurance
Insurance Authority
Authority under under No. (1)
No. (1) dated dated 22/07/1984
22/07/1984 and subject and
to thesubject to the
provisions provisions
of the of No.
Federal Law the (6)
Federal Law
of 2007 No. (6) of 2007.
(as amended).
Public Joint Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
ADNIC-COMU-02-PF04 1/4 2/10
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 ERECTION ALL RISKS
APPLICATION FORM INSURANCE
FOR SHIFA
INIDIVIDUAL/FAMILIES PLANS

APPLICATION FORM FOR SHIFA

1. Proposal details (continued)
1. POLICYHOLDER DETAILS INIDIVIDUAL/FAMILIES PLANS
[Link]
Manufacturer(s) of main items:
......................................................................................................... First name ..................................................................................................

Title ....................................................................................................................
1. POLICYHOLDER DETAILS Date of birth (dd/mm/yyyy) ...................................................................
Name(s) and address(es):
Marital status .................................................................................................... Sex M F
Last name ......................................................................................................... First name ..................................................................................................
Occupation ....................................................................................................... Height (cm) .................................. Weight (kg) ................................
Title .................................................................................................................... Date of birth (dd/mm/yyyy) ...................................................................
Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-
i. Marital
Firm status ....................................................................................................
supervising erection: Sex M F
Nationality ............................................................
Occupation Passport no. .............................................
....................................................................................................... Emirate of visa issuance
Height (cm) .................................. ................................................
Weight (kg) ................................
Namegross
Monthly andsalary
address: Less than AED 4,000/- Greater than AED 4,000/-

Nationality ............................................................ Passport no. ............................................. Emirate of visa issuance ................................................

Address .....................................................................................................................................................................................................................................
j. Consulting engineer:
Town/City ......................................................................................................... Country/State ..........................................................................................

Mobile number.....................................................................................................................................................................................................................................
Address
Name ................................................................................................
and address: Email ..........................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................

Mobile number ................................................................................................ Email ..........................................................................................................

2. k.
COMPANY
Proposer:
DETAILS (if applicable)

Company name ........................................................................................................................................................................................................................

2. COMPANY DETAILS (if applicable)
Please indicate which of the parties from nos 1d. to 1i. above is the Proposer of the insurance and
.....................................................................................................................................................................................................................................
Addresswhich parties are to be declared as Insured in the Policy.
Company name ........................................................................................................................................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................
Address .....................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
Proposer.........................................................................................................
Email Town/City no. : Insured no(s).:
Country/State ..........................................................................................

Email ..........................................................................................................................................................................................................................................
l. Exact description of the property to be erected (if second-hand items are to be erected, please state).
3. DEPENDENTS TO BE manufacturer’s
In case of machines: INCLUDED INname, THE PLAN
number, type, size, capacity, weight, pressure, temperature,
[Link],
DEPENDENTS year TO of construction
BE INCLUDED of major
IN THE units.
PLAN In case of complete factories: general drawing of plant,
Please enter
naturetheof
details
civilofengineering
all the dependents
work to (if
be any).
covered under this policy. This can include your legal spouse and your unmarried,
financially
Pleasedependent children
enter the details under
of all the age of to
the dependents [Link]
The place under
covered of residence of the
this policy. Thislegal spouseyour
can include and legal
the unmarried
spouse andfinancially dependent
your unmarried,
children must bedependent
financially with the Policyholder
children underunless the
the age of Insurance company
18. The place approves
of residence of thethe other
legal arrangements.
spouse and the unmarried financially dependent
children must be with the Policyholder unless the Insurance company approves the other arrangements.
Height Weight Date of birth Emirate of
Last name First name Relation Sex
(cm)
Height (kg)
Weight Date(dof- birth
m - y) Emirate
visa issuance
of
Last name First name Relation Sex
(cm) (kg) (d - m - y) visa issuance
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /

Policyholder is theisperson/company
Policyholder who
the person/company hashas
who thethe
right totoconfirm,
right confirm,alter
alter or
or renew thisinsurance
renew this insurancecover
coveronon behalf
behalf of the
of all all the insured
insured
members underunder
members the same policy,
the same andand
policy, who is responsible
who is responsiblefor
forthe
thepremium
premium payment againstinsurance
payment against insurance cover
cover under
under thisthis policy.
policy.

[Link] 839 - Abu Dhabi, U.A.E. Tel: +971 (0) 2 4080100 Fax: +971 (0) 2 4080604 • [Link] • Toll free: 800 8040 ͧ˻!˯
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Tel: +971 (0) 2 4080100
839 AbuFax: +971-(0) 2 4080604 • [Link] • Toll free:+971(0)
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2 4080604 • [Link] • Toll free: 800 8040 • Email: info@[Link]
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Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
Public Shareholding Company established in 1972 with a paid up capital of AED (375)m, Registered at the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007.
Public Joint Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
1/4
ADNIC-COMU-02-PF04 3/10
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 ERECTION ALL RISKS
APPLICATION FORM INSURANCE
FOR SHIFA
INIDIVIDUAL/FAMILIES PLANS

2. Insurance and limits APPLICATION

of indemnity FORM FOR SHIFA
1. POLICYHOLDER DETAILS INIDIVIDUAL/FAMILIES PLANS
Please state hereunder the amounts you wish to insure or where applicable, the limits of indemnity required
Last name ......................................................................................................... First name ..................................................................................................
(see Policy wording, Section I and Memo 1 and Section II):
Title ....................................................................................................................
1. POLICYHOLDER DETAILS Date of birth (dd/mm/yyyy) ...................................................................
Currency:
Marital status .................................................................................................... Sex M F
Last name ......................................................................................................... First name ..................................................................................................
Occupation ....................................................................................................... Height (cm) .................................. Weight (kg) ................................
Title .................................................................................................................... Date of birth (dd/mm/yyyy) ...................................................................
MonthlySection I–
gross salary Less than AED 4,000/- Greater than AED 4,000/-
Marital status .................................................................................................... Sex M Sums
F to be insured
Material damage Items to be insured
Nationality ............................................................
Occupation Passport no. .............................................
....................................................................................................... Emirate of (state below................................................
visa issuance
Height (cm) ..................................
separately)
Weight (kg) ................................

Monthly gross salary

[Link] than AED 4,000/-
Erection works, splitGreaterup asthan AED 4,000/-
follows:
Nationality 1.1 Items Passport
............................................................ to be erected
no. ............................................. Emirate of visa issuance ................................................

Address .....................................................................................................................................................................................................................................
1.2 Freight
Town/City ......................................................................................................... Country/State ..........................................................................................
1.3 Customs duties and dues
Mobile number.....................................................................................................................................................................................................................................
Address ................................................................................................ Email ..........................................................................................................
Town/City .........................................................................................................
1.4 Cost of erection Country/State ..........................................................................................

Mobile number ................................................................................................ Email ..........................................................................................................

2. Civil engineering works
2. COMPANY DETAILS (if applicable)
3. Construction/erection equipment
Company name ........................................................................................................................................................................................................................
2. COMPANY DETAILS (if applicable)
Clearance of debris
Address .....................................................................................................................................................................................................................................
4.
Company name ........................................................................................................................................................................................................................
(limit of indemnity)
Town/City ......................................................................................................... Country/State ..........................................................................................
Address .....................................................................................................................................................................................................................................
Property located on the principal’s
..........................................................................................................................................................................................................................................
Email Town/City
premises or on the site, belonging to
......................................................................................................... Country/State ..........................................................................................
the principal or held in care, custody or
..........................................................................................................................................................................................................................................
Email 5.
control (limit of indemnity see Memo 4 of
the Policy)
3. DEPENDENTS TO BE INCLUDED IN THE PLAN
3. DEPENDENTS TO BE INCLUDED IN THE PLAN
Please enter the details of all the dependents to be covered under this policy. This can include your legal spouse and your unmarried,
financially
Pleasedependent children
enter the details under
of all
Total sumofto
the age
the dependents to
be
[Link]
Theinsured
covered of under
place under Section
residence of the
this policy.
I can include
Thislegal spouseyour
and legal
the unmarried
spouse andfinancially dependent
your unmarried,
children must bedependent
financially with the Policyholder
children underunless the
the age of Insurance company
18. The place approves
of residence of thethe other
legal arrangements.
spouse and the unmarried financially dependent
children must be with the Policyholder unless the Insurance company approves the other arrangements.
Height Weight Date of birth Emirate of
Last name First name Relation Sex
Please indicate limits of indemnity required (cm) (kg) Date(d
for theWeight
Height following of- birth
m - y)
perils: visa issuance
Emirate of
Last name First name Relation Sex
(cm) (kg) (d - m - y) visa issuance
M F / /
M F / /
M F / /

M
M F
F Limits of/ indemnity
/
/
/
1
Risk
M F / /
M F / /
M F / /
Earthquake, volcanism, tsunamiM F / /
M F / /

Policyholder is theisperson/company
Policyholder Storm,
who
the person/company cyclone,
has
who thethe
has rightflood,
right inundation,
totoconfirm,
confirm,alter
alter or landslide
or renew
renew thisinsurance
this insurancecover
coveronon behalf
behalf of the
of all all the insured
insured
members underunder
members the same policy,
the same andand
policy, who is responsible
who is responsiblefor
forthe
thepremium
premium payment againstinsurance
payment against insurance cover
cover under
under thisthis policy.
policy.

[Link] 839 - Abu Dhabi, U.A.E. Tel: +971 (0) 2 4080100 Fax: +971 (0) 2 4080604 • [Link] • Toll free: 800 8040 ͧ˻!˯
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(0) 2 4080100 Fax:
839 Abu +971 (0)
Dhabi 2 4080604
- U.A.E. [Link]
• Tel: •+971(0) • Toll•free:
2 4080100 Fax: 800 8040
+971(0) 2ͧ˻!˯
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Shareholding Stock Company
Company establishedin
established in 1972
1972 with
withPaid up Capital
a paid of AEDof
up capital 570,000,000 and Registered
AED (375)m, licensed by the
at the zo
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Insurance Authority
Insurance under No.
Authority (1) dated
under 22/07/1984
No. (1) and subject to
dated 22/07/1984 thesubject
and provisions
to of
thetheprovisions
Federal Law
ofNo.
the(6)Federal
of 2007Law
(as amended).
No. (6) of 2007.
Public Joint Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
1/4
ADNIC-COMU-02-PF04 4/10
1/4
 ERECTION ALL RISKS
APPLICATION FORM INSURANCE
FOR SHIFA
INIDIVIDUAL/FAMILIES PLANS

2. Insurance and limitsAPPLICATION FORM FOR SHIFA

of indemnity (continued)
1. POLICYHOLDER DETAILS INIDIVIDUAL/FAMILIES PLANS
Last name .........................................................................................................
Section II – First name ..................................................................................................
Limits of indemnity2
Insured items
Third Party Liability
Title .................................................................................................................... Date of birth (dd/mm/yyyy) ...................................................................
1. POLICYHOLDER DETAILS
Marital status ....................................................................................................
Bodily injury – Any one person Sex M F
Last name ......................................................................................................... First name ..................................................................................................
Occupation ....................................................................................................... Height (cm) .................................. Weight (kg) ................................
Title ....................................................................................................................
Bodily injury – total Date of birth (dd/mm/yyyy) ...................................................................
Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-
Marital status .................................................................................................... Sex M F
Nationality Property damage
............................................................ Passport no. ............................................. Emirate of visa issuance ................................................
Occupation ....................................................................................................... Height (cm) .................................. Weight (kg) ................................

Monthly gross salary OrLess alternatively

than AED 4,000/- Greater than AED 4,000/-

Nationality
Combined single limit of
............................................................ Passport no. ............................................. Emirate of visa issuance ................................................

Address .....................................................................................................................................................................................................................................
1. Limit of indemnity in respect of each and every loss or damage and/or series of
Town/City .........................................................................................................
losses or damage arising outCountry/State ..........................................................................................
of any one event.
number.....................................................................................................................................................................................................................................
Address
Mobile 2. Limit of indemnity in respectEmail
................................................................................................ of any one accident or series of accidents arising
..........................................................................................................
out of one event.
Town/City ......................................................................................................... Country/State ..........................................................................................

Mobile number ................................................................................................ Email ..........................................................................................................

2. COMPANY DETAILS (if applicable)

Company name ........................................................................................................................................................................................................................

2. COMPANY DETAILS (if applicable)
3. Insurance and coverage
Address .....................................................................................................................................................................................................................................
Company name ........................................................................................................................................................................................................................
Town/City .........................................................................................................
a. Period of insurance Country/State ..........................................................................................
Address .....................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
Email Town/City ......................................................................................................... Country/State ..........................................................................................
i) Commencement of insurance:
Email ..........................................................................................................................................................................................................................................
ii) Duration of pre-storage months prior to beginning or erection work.
3. DEPENDENTS TO BE INCLUDED IN THE PLAN
iii) Commencement of erection work:
3. DEPENDENTS TO BE INCLUDED IN THE PLAN
Please enter the details of all the dependents to be covered under this policy. This can include your legal spouse and your unmarried,
financially
Pleasedependent children
enter the details under
of all the age of to
the dependents [Link]
The place under
covered of residence of the
this policy. Thislegal spouseyour
can include and legal
the unmarried
spouse andfinancially dependent
your unmarried,
children must bedependent
financially
b. with the Policyholder
If maintenance children
coverageunderunless the
the age
required:of Insurance company
18. The place approves
of residence of thethe other
legal arrangements.
spouse and the unmarried financially dependent
children must be with the Policyholder unless the Insurance company approves the other arrangements.
Height Weight Date of birth Emirate of
Last name First name Relation Sex
i) Duration of erection/construction: (cm)
Height (kg)
Weight months
Date(dof- birth
m - y) Emirate
visa issuance
of
Last name First name Relation Sex
(cm) (kg) (d - m - y) visa issuance
M F / /
ii) Duration of testing: M F / weeks
/
M F / /
M F / /
iii) Duration of maintenance: M F / /
months
M F / /
M F / /
M F / /
iv) Type of coverage required: / /
M F
M F / /

v) Termination
Policyholder
Policyholder
of insurance:
is theisperson/company who
the person/company hashas
who thethe
right totoconfirm,
right confirm,alter
alter or
or renew thisinsurance
renew this insurancecover
coveronon behalf
behalf of the
of all all the insured
insured
members underunder
members the same policy,
the same andand
policy, who is responsible
who is responsiblefor
forthe
thepremium
premium payment againstinsurance
payment against insurance cover
cover under
under thisthis policy.
policy.

[Link] 839 - Abu Dhabi, U.A.E. Tel: +971 (0) 2 4080100 Fax: +971 (0) 2 4080604 • [Link] • Toll free: 800 8040 ͧ˻!˯
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Tel: +971 (0) 2 4080100
839 AbuFax: +971-(0) 2 4080604 • [Link] • Toll free:+971(0)
800 8040 ͧ˻!˯
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ͨqʙy,Mr [Link] Dhabi U.A.E. • Tel: +971(0) 2 4080100 • Fax: zo
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2 4080604 • [Link] • Toll free: 800 8040 • Email: info@[Link]
ͨqʙy,Mr
Public Joint2007
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 zo
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Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
Public Shareholding Company established in 1972 with a paid up capital of AED (375)m, Registered at the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007.
Public Joint Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
1/4
ADNIC-COMU-02-PF04 5/10
1/4
 ERECTION ALL RISKS
APPLICATION FORM INSURANCE
FOR SHIFA
INIDIVIDUAL/FAMILIES PLANS

4. Project details APPLICATION FORM FOR SHIFA

INIDIVIDUAL/FAMILIES
1. POLICYHOLDER DETAILS PLANS
a. Have plans, designs, and materials of the kind used in this project been used and/or tested in
Last name ......................................................................................................... First name ..................................................................................................

....................................................................................................................
Title 1. POLICYHOLDER
i) Previous constructions? DETAILS Date of birth (dd/mm/yyyy) ...................................................................
Yes No
Marital status .................................................................................................... Sex M F
Last name ......................................................................................................... First name ..................................................................................................
ii) .......................................................................................................
Occupation Previous constructions by the contractor(s)? Yes
Height (cm) .................................. Weight No
(kg) ................................
Title .................................................................................................................... Date of birth (dd/mm/yyyy) ...................................................................
Monthly gross
If so,salary
please Less than AED 4,000/-
give details of similar projects carried out Greater than AED 4,000/-
Marital status .................................................................................................... Sexby contractor(s): M F
Nationality ............................................................
Occupation Passport no. .............................................
....................................................................................................... Emirate of visa issuance
Height (cm) .................................. ................................................
Weight (kg) ................................

Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-

Nationality ............................................................ Passport no. ............................................. Emirate of visa issuance ................................................

Address .....................................................................................................................................................................................................................................

Town/City ......................................................................................................... Country/State ..........................................................................................

b. Is this an extension of an existing plant? Yes No
Address
Mobile .....................................................................................................................................................................................................................................
number ................................................................................................ Email ..........................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................
If so, will operation of existing plant continue during erection period? Yes
Mobile number ................................................................................................ Email ..........................................................................................................
No
Please enclose plans.
2. COMPANY DETAILS (if applicable)
c. Have the buildings and civil engineering works already been completed? Yes No
Company name ........................................................................................................................................................................................................................
2. COMPANY DETAILS (if applicable)
Address .....................................................................................................................................................................................................................................
d. Details
Company of ........................................................................................................................................................................................................................
name work to be carried out by subcontractor. Also provide the values of the work to be carried out.
Town/City ......................................................................................................... Country/State ..........................................................................................
Address .....................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
EmailTown/City ......................................................................................................... Country/State ..........................................................................................

Email ..........................................................................................................................................................................................................................................

3. DEPENDENTS TO BE INCLUDED IN THE PLAN

3. DEPENDENTS TO BE INCLUDED IN THE PLAN
Please enter the details of all the dependents to be covered under this policy. This can include your legal spouse and your unmarried,
financially
Pleasedependent children
enter the details under
of all the age of to
the dependents [Link]
The placeunder
covered of residence of the
this policy. Thislegal spouseyour
can include and legal
the unmarried
spouse andfinancially dependent
your unmarried,
children must be
financially with the children
dependent Policyholder
underunless
the agethe
of Insurance company
18. The place approves
of residence of thethe other
legal arrangements.
spouse and the unmarried financially dependent
5. Risk and hazard information
children must be with the Policyholder unless the Insurance company approves the other arrangements.
Height Weight Date of birth Emirate of
Last name First name Relation Sex
(cm)
Height (kg) Date(dof-birth
Weight m - y) Emirate
visa issuance
of
Please Last
answer
namequestions 5a.
Firstto 5g. to the best
name of your ability.
Relation Sex
(cm) (kg) (d - m - y) visa issuance
M F / /
M F / /
a. Is there any M F / /
M F / /
i) Fire risk? M F / Yes/ No
M F / /
M F / /
ii) Aggravated risk of explosion? M F / Yes
/ No
M F / /
M F / /
If so, please give details:
Policyholder is theisperson/company
Policyholder who
the person/company hashas
who the right
the righttotoconfirm,
confirm,alter
alter or renewthis
or renew thisinsurance
insurance cover
cover onon behalf
behalf of the
of all all the insured
insured
members under
members the same
under policy,
the same andand
policy, who is responsible
who is responsiblefor
forthe
thepremium paymentagainst
premium payment againstinsurance
insurance cover
cover under
under thisthis policy.
policy.

b. Please provide details of ground water level:

[Link] 839 - Abu Dhabi, U.A.E. Tel: +971 (0)

[Link] 8392 4080100 Fax: +971
Abu Dhabi (0) 2 •
- U.A.E. 4080604 • [Link]
Tel: +971(0) 2 4080100• Toll free:+971(0)
• Fax: 800 8040 ͧ˻!˯
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• [Link] ͧ6\T
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Tel: +971 (0) 2 4080100 Fax: +971 (0) 2 4080604 • [Link] • Toll free: 800 8040 ͧ˻!˯
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839
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ͨqʙy,Mr zo
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KsT,˯
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1972
cL
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Public Shareholding Company established in 1972 with a paid up capital of AED (375)m, Registered at the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007.
ͨqʙy,Mr
Public Joint2007
kȽȽ5`
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(1)
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 zo
t,`
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gX/r
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570,000,000
KsT,˯
p`˴ȽȽ4/
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cL
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Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
Public Joint Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
ADNIC-COMU-02-PF04 1/4 6/10
1/4
 ERECTION ALL RISKS
APPLICATION FORM INSURANCE
FOR SHIFA
INIDIVIDUAL/FAMILIES PLANS

APPLICATION
5. Risk and hazard information (continued) FORM FOR SHIFA
1. POLICYHOLDER DETAILSINIDIVIDUAL/FAMILIES PLANS
.........................................................................................................
c. Nearest
Last name river, lake, sea, etc. First name ..................................................................................................

....................................................................................................................
Title 1. POLICYHOLDER DETAILS Date of birth (dd/mm/yyyy) ...................................................................
i) Name:
Marital status .................................................................................................... Sex M F
Last name ......................................................................................................... First name ..................................................................................................
ii) Distance from site:
Occupation ....................................................................................................... Height (cm) .................................. Weight (kg) ................................
Title .................................................................................................................... Date of birth (dd/mm/yyyy) ...................................................................
Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-
Marital status .................................................................................................... Sex M F
d. Levels of such river, lake, sea, etc.
Nationality ............................................................
Occupation Passport no. .............................................
....................................................................................................... Emirate of visa issuance
Height (cm) .................................. ................................................
Weight (kg) ................................
i) gross
Monthly Lowsalary
water: Less than AED 4,000/- Greater than AED 4,000/-

Nationality ............................................................ Passport no. ............................................. Emirate of visa issuance ................................................

ii) Mean water:
Address .....................................................................................................................................................................................................................................
iii) Highest level recorded:
Town/City ......................................................................................................... Country/State ..........................................................................................
Address iv) Mean level of site:
.....................................................................................................................................................................................................................................
Mobile number ................................................................................................ Email ..........................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................
e. Meteorological conditions
Mobile number ................................................................................................ Email ..........................................................................................................
i) Rainy seasons: From: To:
2. COMPANY DETAILS (if applicable)
ii) Max rainfall (mm): Per hour: Per day: Per month:
Company name ........................................................................................................................................................................................................................
2. COMPANY DETAILS (if applicable)
iii) Max wind velocity:
Address .....................................................................................................................................................................................................................................
Company name ........................................................................................................................................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................
iv) .....................................................................................................................................................................................................................................
Address Storm frequency Low Medium High
..........................................................................................................................................................................................................................................
EmailTown/City ......................................................................................................... Country/State ..........................................................................................
f. Hazards of earthquake, volcanism, tsunami
Email ..........................................................................................................................................................................................................................................

i) Is there a history of volcanism, tsunami at the site? Yes No

3. DEPENDENTS TO BE INCLUDED IN THE PLAN
3. DEPENDENTS TO BE etc.
ii) Have earthquakes, INCLUDED IN THEinPLAN
been observed this area? Yes No
Please enter the details of all the dependents to be covered under this policy. This can include your legal spouse and your unmarried,
financially
Ifdependent
Please so, please
enter children
state
the details under
the
of all the age of
theintensity [Link]
magnitude:
dependents to placeunder
covered of residence of the
this policy. Thislegal spouseyour
can include andlegal
the unmarried
spouse andfinancially dependent
your unmarried,
children must be
financially with the children
dependent Policyholder
underunless
the agethe Insurance
of 18. company
The place approves
of residence of the the
legalother arrangements.
spouse and the unmarried financially dependent
children must be with the Policyholder unless the Insurance company approves the other arrangements.
Height Weight Date of birth Emirate of
Last name First name Relation Sex
(cm)
Height (kg) Date(d
Weight of-birth
m - y) Emirate
visa issuance
of
Last name
g. Subsoil conditions First name Relation Sex
(cm) (kg) (d - m - y) visa issuance
M F / /
M F / /
i) Is the design of the structures to be insured based
M on regulations
F regarding earthquake
/ /
M F / /
M F / /
resistant structures? M F / / Yes No
M F / /
M F / /
ii) Rock Gravel Sand
M
M F
F Clay /
/
/
/ Filled site

iii) Other
Policyholder is the
Policyholder types:
is person/company
the who
person/company has
who the
has theright
righttotoconfirm,
confirm, alter or renew
alter or renewthis
thisinsurance
insurance cover
cover on on behalf
behalf ofthe
of all all insured
the insured
members under
members the same
under policy,
the same andand
policy, who is is
who responsible
responsiblefor
forthe
the premium paymentagainst
premium payment againstinsurance
insurance cover
cover under
under thisthis policy.
policy.

iv) Do geological faults exist in the vicinity? Yes No

[Link] 839 - Abu Dhabi, U.A.E. Tel: +971 (0) 2 4080100 Fax: +971 (0) 2 4080604 • [Link] • Toll free: 800 8040 ͧ˻!˯
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[Link] 839 - Abu Dhabi, [Link] 839 Abu Dhabi
+971 -(0)
U.A.E. • Tel: +971(0) 2 4080100
U.A.E.2007
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Tel: +971 (0) 2 4080100 Fax: 2 4080604 • [Link] • free:
• Toll Fax: +971(0)
800 8040 2 ͧ˻!˯
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4080604 • [Link] • Toll free:
• +971 (0) 2 4080604 800 8040
ͧ6\T • Email:
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1972
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ͨqʙy,Mr
Public Shareholding Company established
established in 1972 with a up
paid up capital
of AED of AED (375)m,
Public Joint 2007
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Stock Company in 1972 with Paid Capital 570,000,000 Registered
and licensed by the zo
t,`
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570,000,000
KsT,˯
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1972
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at Insurance
the Insurance Authority
Authority under
under No. No. 22/07/1984
(1) dated (1) dated 22/07/1984
and subject toand
the subject toofthe
provisions theprovisions
Federal LawofNo.
the(6)Federal
of 2007Law No. (6) of 2007.
(as amended).
Public Joint Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
ADNIC-COMU-02-PF04 1/4 7/10
1/4
 ERECTION ALL RISKS
APPLICATION FORM INSURANCE
FOR SHIFA
INIDIVIDUAL/FAMILIES PLANS

APPLICATION
5. Risk and hazard information (continued) FORM FOR SHIFA
1. POLICYHOLDER DETAILSINIDIVIDUAL/FAMILIES PLANS
Last name ......................................................................................................... First name ..................................................................................................
h. Estimate, if possible, the probable maximum loss, expressed as a percentage of the sum insured, in a
Title 1. single occurrence.
....................................................................................................................
POLICYHOLDER DETAILS Date of birth (dd/mm/yyyy) ...................................................................

Marital status .................................................................................................... Sex M F

Last i) Due
name to earthquake:
......................................................................................................... First name ..................................................................................................
Occupation ....................................................................................................... Height (cm) .................................. Weight (kg) ................................
Title .................................................................................................................... Date of birth (dd/mm/yyyy) ...................................................................
ii) Due to fire:
Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-
Marital status .................................................................................................... Sex M F
iii) ............................................................
Nationality Due to other cause (please Passport specify): no. ............................................. Emirate of visa issuance ................................................
Occupation ....................................................................................................... Height (cm) .................................. Weight (kg) ................................

Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-

Nationality ............................................................ Passport no. ............................................. Emirate of visa issuance ................................................

Address .....................................................................................................................................................................................................................................

Town/City ......................................................................................................... Country/State ..........................................................................................

6. Insurance requirements
Address .....................................................................................................................................................................................................................................
Mobile number ................................................................................................ Email ..........................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................
a. Is coverage of construction/erection equipment (scaffolding, temporary site offices, tools, etc.)
Mobile number ................................................................................................ Email ..........................................................................................................
required? Yes No
2. COMPANY DETAILS (if applicable)

Please give a brief description and state the new replacement value under question 2 Section I pt 3:
Company name ........................................................................................................................................................................................................................
2. COMPANY DETAILS (if applicable)
Address .....................................................................................................................................................................................................................................
Company name ........................................................................................................................................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................
Address .....................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
EmailTown/City ......................................................................................................... Country/State ..........................................................................................
b. Is ..........................................................................................................................................................................................................................................
Email coverage of construction/erection equipment (excavators, cranes, etc.) required? Yes No

Please attach a list of major machines showing individual new replacement values and state total value:
3. DEPENDENTS TO BE INCLUDED IN THE PLAN
3. DEPENDENTS TO BE INCLUDED IN THE PLAN
Please enter the details of all the dependents to be covered under this policy. This can include your legal spouse and your unmarried,
financially
Pleasedependent children
enter the details under
of all the age of to
the dependents [Link]
The placeunder
covered of residence of the
this policy. Thislegal spouseyour
can include andlegal
the unmarried
spouse andfinancially dependent
your unmarried,
children must be
financially with the children
dependent Policyholder
underunless
the agethe Insurance
of 18. company
The place approves
of residence of the the other
legal arrangements.
spouse and the unmarried financially dependent
children
c. Aremust be withbuildings
existing the Policyholder unless
and/or the Insurance
structures oncompany approvesto
or adjacent thethe
other arrangements.
site,
Height Weight or
owned by
held
Date in care,Emirate
of birth custodyof
Last name First name Relation Sex
orLast
control of the contractor(s) or the principal, to be insured (cm) Weight
against
Height (kg)
loss or Date(d
damageof-birth
m arising
- y) Emirate
visa
outissuance
of
of or
name First name Relation Sex
(cm) (kg) (d - m - y) visa issuance
in connection with the contract works? State limit underM question
F 2 Section I pt /5. /
M F / /
M F / /
M F / /
M F / Yes
/ No
M F / /
M
If so, give exact description of these buildings/structures: F / /
M F / /
M F / /
M F / /

Policyholder is theis person/company

Policyholder who
the person/company has
who the
has right
the righttotoconfirm,
confirm, alter or renew
alter or renewthis
thisinsurance
insurance cover
cover onon behalf
behalf ofthe
of all all the insured
insured
members under
members the same
under policy,
the same andand
policy, who is is
who responsible
responsiblefor
forthe
thepremium paymentagainst
premium payment againstinsurance
insurance cover
cover under
under thisthis policy.
policy.

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Stock Companyestablished
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provisions theprovisions ofNo.
Federal Law the(6)Federal
of 2007Law No. (6) of 2007.
(as amended).
Public Joint Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
ADNIC-COMU-02-PF04 1/4 8/10
1/4
 ERECTION ALL RISKS
APPLICATION FORM INSURANCE
FOR SHIFA
INIDIVIDUAL/FAMILIES PLANS

APPLICATION
6. Insurance requirements (continued) FORM FOR SHIFA
INIDIVIDUAL/FAMILIES PLANS
1. POLICYHOLDER DETAILS

Last name ......................................................................................................... First name ..................................................................................................

d. Do you wish cover to include extra charges (in case of loss) for express freight, airfreight, overtime,
....................................................................................................................
Title 1. POLICYHOLDER DETAILS Date of birth (dd/mm/yyyy) ...................................................................
nightwork, work on public holidays? Yes No
Marital status .................................................................................................... Sex M F
Last name ......................................................................................................... First name ..................................................................................................
e. Give
Occupation details of any special extension of cover required:
....................................................................................................... Height (cm) .................................. Weight (kg) ................................
Title .................................................................................................................... Date of birth (dd/mm/yyyy) ...................................................................
Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-
Marital status .................................................................................................... Sex M F
Nationality ............................................................
Occupation Passport no. .............................................
....................................................................................................... Emirate of visa issuance
Height (cm) .................................. ................................................
Weight (kg) ................................

Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-

Nationality ............................................................ Passport no. ............................................. Emirate of visa issuance ................................................

7. Additional information
Address .....................................................................................................................................................................................................................................

Town/City ......................................................................................................... Country/State ..........................................................................................

AddressPlease attach a copy of the following:
.....................................................................................................................................................................................................................................
Mobile number ................................................................................................ Email ..........................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................
• Scope of work
Mobile number ................................................................................................ Email ..........................................................................................................
• Work method statement
2. COMPANY DETAILS (if applicable)
• Site layout
Company name ........................................................................................................................................................................................................................
2. COMPANY DETAILS (if applicable)
• .....................................................................................................................................................................................................................................
Address Bar chart
Company name ........................................................................................................................................................................................................................
Town/City .........................................................................................................
• Breakdown of contract value Country/State ..........................................................................................
Address .....................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
EmailTown/City ......................................................................................................... Country/State ..........................................................................................
• Loss prevention and minimization measures
Email ..........................................................................................................................................................................................................................................
• Details of surrounding and existing buildings and/or structures not belonging to the principal or
contractor(s)TO
3. DEPENDENTS (enclose maps)
BE INCLUDED IN THE PLAN
3.
• DEPENDENTS TO BE INCLUDED
Any other documents IN risk
regarding the THE PLAN
Please enter the details of all the dependents to be covered under this policy. This can include your legal spouse and your unmarried,
financially
Pleasedependent children
enter the details of allunder the age [Link]
the dependents placeunder
covered of residence of This
this policy. the legal spouseyour
can include andlegal
the unmarried
spouse and financially dependent
your unmarried,
children must be
financially with thechildren
dependent Policyholder
under unless
the agethe Insurance
of 18. company
The place approves
of residence the other
of the legal arrangements.
spouse and the unmarried financially dependent
children must be with the Policyholder unless the Insurance company approves the other arrangements.
Height Weight Date of birth Emirate of
Last name First name Relation Sex
(cm) Weight
Height (kg) Date(dof -birth
m - y) Emirate
visa issuance
of
Last name First name Relation Sex
(cm) (kg) (d - m - y) visa issuance
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /

Policyholder is the
Policyholder person/company
is the who
person/company has
who hasthe
theright
rightto
toconfirm, alter or
confirm, alter orrenew
renewthis
thisinsurance
insurance cover
cover on on behalf
behalf ofthe
of all all insured
the insured
members under
members the the
under same policy,
same and
policy, who
and is isresponsible
who responsiblefor
for the
the premium paymentagainst
premium payment against insurance
insurance cover
cover under
under this this policy.
policy.

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[Link] Fax:
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Public Joint Stock Companyestablished
Company established in
in1972
1972with Paidaup
with Capital
paid of AED 570,000,000
up capital and licensed
of AED (375)m, by the
Registered zo
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atInsurance Authority
the Insurance under No.
Authority (1) dated
under No.22/07/1984
(1) dated and subject toand
22/07/1984 the provisions
subject toofthe
theprovisions
Federal Lawof
No. (6)Federal
the of 2007 Law
(as amended).
No. (6) of 2007.
Public Joint Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
1/4
ADNIC-COMU-02-PF04 9/10
1/4
 ERECTION ALL RISKS
APPLICATION FORM INSURANCE
FOR SHIFA
INIDIVIDUAL/FAMILIES PLANS

Declaration APPLICATION FORM FOR SHIFA

INIDIVIDUAL/FAMILIES PLANS
1. POLICYHOLDER DETAILS

I/We
Last .........................................................................................................
namehereby declare that the statements/informationFirst given by..................................................................................................
name me/us in the Proposal Form are full,
accurate
Title and true. It isDETAILS hereby understood and agreed
....................................................................................................................
1. POLICYHOLDER that
Date the statements,
of birth answers and particulars
(dd/mm/yyyy) ...................................................................
provided in this Proposal Form and as per the attachments are the
Marital status .................................................................................................... Sex M
basisFon which the insurance
Last name .........................................................................................................
policy is being issued/effected. If after the insurance policy is effected, it is found that any fact First name ..................................................................................................
Occupation ....................................................................................................... Height (cm) .................................. Weight (kg) ................................
in Title
the ....................................................................................................................
statements, answers or particulars in this Proposal Date of birth Form is incorrect,
(dd/mm/yyyy) untrue, inaccurate,
...................................................................
Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-
misrepresented or non-disclosed in any material respect,
Marital status .................................................................................................... Sex ADNIC M shall have F no liability under the
insurance
Nationality ............................................................
Occupationpolicy and/or shall have the right to terminate Passport no. .............................................
....................................................................................................... Height the (cm) insurance Emirate of policy
visa
..................................issuance
Weight from ................................................
(kg) inception.
................................

Monthly gross salary Less than AED 4,000/- Greater than AED 4,000/-

Nationality ............................................................ Passport no. ............................................. Emirate of visa issuance ................................................

Name of Proposer:
Address .....................................................................................................................................................................................................................................

Town/City ......................................................................................................... Country/State ..........................................................................................

Title:
number.....................................................................................................................................................................................................................................
Address
Mobile ................................................................................................ Email ..........................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................

Mobile number ................................................................................................ Email ..........................................................................................................

Signature:
2. COMPANY DETAILS (if applicable)

Company name ........................................................................................................................................................................................................................

2. COMPANY DETAILS (if applicable)
Stamp:
Address .....................................................................................................................................................................................................................................
Company name ........................................................................................................................................................................................................................
Town/City ......................................................................................................... Country/State ..........................................................................................
Address .....................................................................................................................................................................................................................................
..........................................................................................................................................................................................................................................
Email Town/City
Date: ......................................................................................................... Country/State ..........................................................................................

Email ..........................................................................................................................................................................................................................................

3. Note:
DEPENDENTS TOeach
Please note that BE INCLUDED IN THE
page of the Proposal PLAN
Form should be signed by the Proposer or its legal representative
3. DEPENDENTS TO BE INCLUDED IN THE PLAN
Please enter the details of all the dependents to be covered under this policy. This can include your legal spouse and your unmarried,
financially
Pleasedependent children
enter the details under
of all the age of to
the dependents [Link]
The place under
covered of residence of the
this policy. Thislegal spouseyour
can include and legal
the unmarried
spouse andfinancially dependent
your unmarried,
children must bedependent
financially with the Policyholder
children underunless the
the age of Insurance company
18. The place approves
of residence of thethe other
legal arrangements.
spouse and the unmarried financially dependent
children must be with the Policyholder unless the Insurance company approves the other arrangements.
Height Weight Date of birth Emirate of
Last name First name Relation Sex
(cm)
Height (kg)
Weight Date(dof- birth
m - y) Emirate
visa issuance
of
Last name First name Relation Sex
(cm) (kg) (d - m - y) visa issuance
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /
M F / /

Policyholder is theisperson/company
Policyholder who
the person/company hashas
who thethe
right totoconfirm,
right confirm,alter
alter or
or renew thisinsurance
renew this insurancecover
coveronon behalf
behalf of the
of all all the insured
insured
members underunder
members the same policy,
the same andand
policy, who is responsible
who is responsiblefor
forthe
thepremium
premium payment againstinsurance
payment against insurance cover
cover under
under thisthis policy.
policy.

[Link] 839 - Abu Dhabi, U.A.E. Tel: +971 (0) 2 4080100 Fax: +971 (0) 2 4080604 • [Link] • Toll free: 800 8040 ͧ˻!˯
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[Link] Fax:
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Dhabi 2 4080604
U.A.E. • [Link]
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2 4080100 • free: 800 8040
Fax: +971(0) 2 ͧ˻!˯
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Public Joint2007
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Public Shareholding Stock Company
Company establishedinin1972
established 1972 with
withPaid up Capital
a paid of AEDof570,000,000
up capital AED (375)m,andRegistered
licensed by the
at the zo
t,`
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KsT,˯
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Insurance Authority
Insurance under No.
Authority (1) dated
under 22/07/1984
No. (1) and subject to
dated 22/07/1984 andthesubject
provisions of the
to the Federal Law
provisions ofNo.
the(6) of 2007Law
Federal (as amended).
No. (6) of 2007.
Public Joint Stock Company established in 1972 with Paid up Capital of AED 570,000,000 and licensed by the Insurance Authority under No. (1) dated 22/07/1984 and subject to the provisions of the Federal Law No. (6) of 2007 (as amended).
1/4
ADNIC-COMU-02-PF04 10/10
1/4