‘Bajaj Allianz Life Insurance Company Limited @BA3A3|Alanz @ (Pam porta Pat st 2) GO Fo 29) 440 Foreign Travel and Residence Supplementary Statement INSTRUCTIONS FOR FILING UP THE FORM:- 1 This formis to be file by the Proposer himself/herself in BLOCK LETTERS in blue ink 2. Please tick a box thus [Zl where appropriate, 3. Please trie ou pars, which ae not applicable and wrt N.-strakes of he pon, dots and dathes wilnot he acepted a replies. 4 Form filing person must aff his/her ful signature for any cancellation/correctionflteration 5. Forming person must affix his/her fll signature on each page / side ofthe form, (This statement should be completed by the person to be assured) Avpiation nunber [5191 4O IAI LIV12 owe: LI L71019|2}o] 1 Propose! Number: Sed aa 3 Gi Bad aa Waa G ase nin eeepc Proposer Please answer each question and where appropriate provide particulars. 1.2) Do you presently or intended to travel or reside abroad? b) If Yes, please indicate the countryies) involved and ==_KU WAIT. ‘the purpose and planned duration of your stay. JOR; 1 NU 2.a) Where do you or will you stay in the above mentioned -_MANGAE counteylies)? Please speci clty(ies) name ) will you be staying at above location /s throughout. © YRS your stay travel 7 IF“ No“, where else you | willbe staying 2 | ©) Where will/are you staying abroad ? - APARTMENT | Hotel, an apartment, House, shared accomodation, Camp, Barrack, Hut, Oil Rig, other-Pl specify Do you intend to travel remote rural areas ofthe country :-__ NO. if so please provide detail of travel mode and purpose 3. Are adequate Medical facilities avilable near to your yes stay location 2 Distance from nearest multi speciality ADEN HOSPITAL ; SEMS AWAY hospital and name, Address of the Hospital ? 4) 4. Please specify your occupation and give details of the work -_FISE SOC; ALIST BACAD IN THE ‘you are engaged or will be engaged in abroad ? MEAD OFFICE ( multiple option can be selected) For eg, Sedentary, Commerical, Manual Labour only, Partly manual Labour, Managerial, Supervisory, Operating Machines, Research, NGO, Driving motor vehicle, Travelling using own vehicle, public transport, scheduled flight, chartered Flight, On Oil rig, Offshore or Onshore, others 5.Name and address of employer with your current - KowAiT DRiuL ing Cam PArey PO 0 BOX designation 4066, G, ARMAHT 76 001 ku WAT 6.How will you describe political situation in the county? -_ STA@LE (Stable, Civil Commotion, Tribal Warfare, Civil War, War) | hereby declare that the above answers and statement are true and complete and agree that this questionnaire together ‘with the proposal dated shall form part of the contract between me and the company. Place Kaeo dod bate L704 2018 sleatre oe Asred | Witness Name & Address: Signature of Witness Place & date