Application Form

DocuSign Envelope ID: B1ACA8F2-64E7-4970-9775-6D0B9DBDAEA3
International Term Assurance

Application form Financial professional use only
Agency number 8920001
Bank/Broker name ADCB (DST&MRT&INV&EUL)
External reference number NIL
Please read the International Term Assurance Policy conditions, Key features/Customer product disclosure/Key Information document carefully before you complete
this application form. Copies are available on our website zurich.ae.
Please ensure all questions are answered fully and honestly. Incorrect or incomplete information could invalidate your insurance claim and your beneficiaries may not
receive the claim amount.
1 Policy owner(s) details
Policy owner 1
Title Mr
First name MANMOHAN
Family name BANSAL
Any previous names or alias used, including maiden name (if applicable) N.A.
Date of birth 1 January 1975
Gender Male
Occupation Business Owner
Country of birth India
Nationality India
Dual nationality (if applicable) N.A.
Relationship to life insured (if life insured is different than policy owner)
SELF
Residential address
Flat/villa number FLAT NO.: 706
Property/building name Fathima Ali Owais
Area Al Mankhoul
City dubai
Country United Arab Emirates
Page 1 of 13
Policy owner(s) details(continued)
Policy owner 1
Correspondence address
City N.A.
Country N.A.
P.O. Box number N.A.
Mobile number (include international country code)

+971 525192145
Telephone number (optional)

(include international country code)
N.A.
Email address nribanking75@gmail.com
Are you a politically exposed person? No
Politically exposed persons are individuals or international entities who are or have been entrusted with prominent public functions and their immediate family
members and close associates. A full description can be found in the ‘Customer’s guide to AML’.
2 Life/Lives Insured Details
Life to be insured 1
Title Mr
Family Name BANSAL
Forename(s) MANMOHAN
Please give details of any previous names or alias used, including maiden name
(if applicable) N.A.
Date of birth 1 January 1975
Gender Male
Nationality India
Occupation Business Owner
Current Residential address
Property/building name Fathima Ali Owais
Area Al Mankhoul
City dubai
Page 2 of 13
Life/Lives to be insured (continued)
Life to be insured 1
Correspondence address
P.O. Box number N.A.
City N.A.
Country N.A.
Telephone number N.A.
Mobile number +971 525192145
If your application includes any benefits (e.g. life cover, critical illness, waiver of
premium, etc), have you smoked or used any form of tobacco or nicotine
product in the past 12 months (e.g. cigarettes, cigars, pipe or chewing tobacco
or nicotine products such as patches, gum or ecigarettes)? No
3 Premium details
Policy Currency USD
Premium Amount 154.30 (in policy currency)
Premium Frequency Monthly
4 Protection benefits
Please state the amount of cover required in the policy currency.
Compulsory benefits: Amount
Life Cover 100,000
Additional benefits:
Critical illness benefit 100,000
Permanent and total disability benefit 100,000
Waiver of premium benefit Life insured 1 Yes Life insured 2 N.A.
5 Proof of identity
The policy owner(s) and third party payor must provide a valid and certified copy of their ID.
a) Passport copy – including signature page and residence visa (expats)
b) Government issued identity card (both sides)
Please refer to the “Customer’s guide to AML” for further information on proof of ID and certification of copy documents.
Page 3 of 13
6 Payor details
Primary payor MANMOHAN BANSAL Premiums for this policy will be paid from my salary/business income Yes
Annual Income 100000 USD
Job Title INVESTOR
Would you like this policy to replace an existing Zurich plan? No
Page 4 of 13
7 Request for conditional assignment

No conditional assignment.
Page 5 of 13
8 Beneficiary nomination
This beneficiary nomination is applicable for both lives. To appoint a separate set of beneficiaries for each life insured, please complete the ‘Appointment of
beneficiary’ form and submit with this application.
Primary Beneficiary 1
Title Mr
First Name RIYANSH
Family Name BANSAL
Date of Birth 7 January 2013
Relationship to life insured SON
Residential Address
Building/property name Fathima Ali Owais
Area Al Mankhoul
City dubai
Share percentage 100
Page 6 of 13
9 Relevant financial professional’s details and declaration
To be completed by your relevant financial professional
First name Sujit Kumar Last name Pandey
Email address sujit.pandey@adcb.com
Contact number N.A.
Declaration
I declare that, to the best of my knowledge and belief, the information given is true and shall form the basis of the proposed contract with Zurich International Life
Limited.
I confirm that I have met the customer whether in person or virtually, and that no third parties have been involved in providing the advice or the collection/certification
of the customer due diligence documentation (where applicable) at any stage of the policy application process.
Signature \FA\
\FAD\
Date 07-Sep-2022 | 10:16:43 ARBST
Page 7 of 13
10 Privacy notice
This Notice is a summary of our (Zurich International Life Limited “the Company”) Privacy Policy which describes how we collect and use personal information as Data
Controller. For the full version please visit online
https://www.zurichinternational.com/en/zurich-international-life/about-us/privacy or contact us for a copy.
Personal information we use How long we hold personal information for
We use personal information such as name and contact details (“Personal Data”) We retain personal information for as long as is necessary to meet the purposes
and sensitive personal information such as medical details (“Special Category for which it was originally collected or to satisfy our legal obligations.
Data”). Data subject rights
What we do with personal information The person who is the subject of the personal information (the “Data Subject”)
We use personal information to provide financial services, for example has the following legal rights:
processing in connection with: access to personal information
setting up and managing a contract of insurance data rectification where it is inaccurate or incomplete
providing marketing information with consent erasure of personal information
complying with our legal obligations to restrict the processing of personal information
running our business where we have a legitimate interest to do so. data portability – to obtain personal information in a digital format
to object to the processing of personal information
Without accurate and sufficient personal information where required, we cannot
to not be subject to automated individual decision making processes.
offer financial services.
to withdraw consent at any time where processing is based on consent.
Sharing of personal information
We obtain personal information from, and share personal information with If you have cause for complaint regarding our processing of personal
other organisations such as: information, you can contact the Isle of Man Information Commissioner.
Zurich Insurance Group Ltd. or any of its affiliated companies Data Protection contact
companies who supply services to us such as administration Email our Data Protection Officer at ZILLPrivacy@Zurich.com.
healthcare service providers Write to our Data Protection Officer or call Zurich HelpPoint by using the
financial advisors and employers where appropriate details on the `contact us’ page of our website zurich.ae.
How we transfer personal information to other countries

As a global business we ensure that personal information is equally protected in
all locations by complying with data protection laws of the EU, Isle of Man and
of each location in which we operate.
11 Declaration/Consent
If you are buying this policy in the United Arab Emirates
The Isle of Man Financial Services Authority’s Insurance (Conduct of Business) (Long Term Business) Code 2021 requires Isle of Man authorised insurers to put in place
measures to ensure the fair treatment of its customers, including providing you with information about this insurance product to help you understand the nature, risks
and cost of this product. As this product is being sold to you through your intermediary in the United Arab Emirates, the insurer is not obliged under local regulations
to provide you with the same information.
If you have any questions about the information that has been provided to you in deciding to purchase this product, you should raise them with your adviser. In the
event of any issues or concerns regarding the sale of the product, recourse for complaints will be to your adviser.
Declaration
I/We apply for an International Term Assurance policy as detailed in this application form and in accordance with Zurich International Life Limited (the Company)
standard terms and conditions. I/We declare that I/We have reviewed the answers given in this application, whether in my/our handwriting or not, and are true and
complete to the best of my/our knowledge and belief, and will form the basis of my/our contract of life insurance.
I/We will tell the Company, in writing, if anything happens between completing this application and the commencement date of the policy that alters any of the
answers I/we have given in this application form. Specifically, I/we will advise on any changes to the details provided by me/us in the health and lifestyle questionnaire
sections contained within the application or any other circumstances which happen before the policy commencement, if that change makes any of my/our answers
wrong or incomplete.
I/We understand that failure to disclose any material fact may invalidate the contract resulting in the loss of benefits.
Note: a material fact is one which may influence the assessment or acceptance of your application for insurance. If you are in any doubt as to the relevance of any
information, please give details.
I/We confirm that I/we understand that a change in my/our country of residence, or that of any life insured, could mean that the Company may no longer be able to
provide all the benefits under this policy.
I/We declare that any premiums that I/we pay to the policy will not contravene any applicable exchange controls regulations or trade or economic sanctions and that
any premium paid to the Company is not of criminal origin or directly or indirectly related to criminal activities or any actual or attempted money laundering or tax
evasion.
Contact details
I/We understand that for security purposes, the Company will regard the contact details provided as my/our authorised contact details and that it is important that
I/We let the company know if any of these details change.
Page 8 of 13
Declaration/Consent (continued)
Marketing consent
The Company, or the Zurich group companies, may wish to contact you by mail, email, telephone or other appropriate means about carefully selected products,
services or offers that may be of interest to you.
I/we consent to being contacted in this way for this purpose Yes
Special category data consent

By signing below, I/We consent to the Company processing my/our medical and health information and authorise the seeking and processing of information from any
medical practitioner who has attended me/us or from any insurer to which an application has been made for insurance. I/We confirm such authorisation shall remain
in force after my/our death.
Withdrawal of consent
I/We understand that where I/we have provided consent I/we have the right to withdraw the consent at any time and that such withdrawal will not affect the data
processing carried out prior to such withdrawal.
I/We confirm that this/these signature(s) below is/are mine/ours or that/those of my/our appointed legal representative(s).
If your signature is different from the signature in your passport/ID, or does not exist on the passport/ID, you will need to complete a ‘Certifying signature form’.
Country where this application is signed United Arab Emirates
Signature of policy owner 1
\PO1\
Print name MANMOHAN BANSAL

\PO1D\
Date 07-Sep-2022 | 10:16:15 ARBST
Signature of life insured 1 (if different to policy owner)
\LI1\

\LI1D\
Date 07-Sep-2022 | 10:16:15 ARBST
We will let you know when cover on the benefits you have selected starts. This will be subject to:
i) The final underwriting decision;
ii) Receipt of the initial premium payment;
iii) Receipt of satisfactory proof of identity and any other documentation we require.
Zurich International Life Limited is registered (Registration No. 63) under UAE Federal Law Number 6 of 2007, and its
activities in the UAE are governed by such law.
Zurich International Life is a business name of Zurich International Life Limited which provides life assurance, investment
and protection products and is authorised by the Isle of Man Financial Services Authority.
Registered in the Isle of Man number 20126C.
Registered office: Zurich House, Isle of Man Business Park, Douglas, Isle of Man, IM2 2QZ, British Isles.
Telephone +44 1624 662266 Telefax +44 1624 662038 www.zurichinternational.com
MSP10044 (134174018) (07/20) CMS

Page 9 of 13
International Term Assurance

Temporary life cover terms and conditions
Qualifying conditions Exclusions

(a) A payment or payment instruction must be submitted with the Notwithstanding the above this cover note will not be valid if:
application form to the value of the minimum initial regular premium
payable under the policy applied for on the application form. (a) it has been altered or modified in any way or;
(b) The proposed life or lives to be insured must not be older than 74 (b) if the payment in respect of the initial premium under the policy is
years attained as at the date of issue of this cover note. not honoured on the first presentation for payment;
(c) there is any material misrepresentation in this cover note, the

Life cover application form or any other supplementary forms;
The amount of life cover provided by this cover note is the lesser of the (d) the death of a proposed life to be insured during the period of
amount of life cover benefit applied for under the application form or cover is by suicide;
USD250,000. This cover note is in respect of life cover benefit applied
for only, and does not apply to any other benefit, other supplementary (e) a proposed life to be insured has in the past five years had or been
applications or additional or alternative policies for which application diagnosed as having, or has been treated by a physician or medical
has been made. professional for:
cancer, or any malignant tumour or growth including melanoma,

Period of cover
angina, heart attack, coronary artery disease, heart or brain surgery,
This cover note is valid from the date Zurich International Life Limited stroke, diabetes, psychosis or other form of mental disease, alcoholism
(‘the Company’) receives a fully completed application form, in or drug addiction, Acquired Immune Deficiency Syndrome (AIDS), HIV
conjunction with the first premium or a valid payment instruction until virus infection, or any other disabling disease or condition;
the earlier of the following dates:
(f) a proposed life to be insured has ever been declined, postponed or
(a) The date the policy becomes effective. accepted on special terms for life cover in the past;
(b) At midnight (local time) on the sixtieth (60th) day after risk (g) death or disappearance is caused directly by or resulting from or in
commenced under this cover note. any way related to:
(c) The date of issue by the Company of a notice that cover has been (i) war or warlike operations (whether war be declared or not)
declined, postponed or a counter offer is issued. including invasion, act of foreign enemy, hostilities, mutiny, riot, civil
commotion, civil war rebellion, insurrection, conspiracy, military or
Where the application is for a joint life policy and one of the proposed usurped power, martial law or state of siege, or any of the events or
lives to be insured dies during the period of temporary life cover, cover causes which determine the proclamation or maintenance of martial
on the other life will be cancelled with effect from the date of death of law or state of siege;
the deceased life. If appropriate, a new application form will then be
requested from the surviving life. (ii) acts of terrorism including any related act or activity that is
dangerous to human life or property, whether claimed or not.
(h) the death of a proposed life to be insured occurs directly or

indirectly as a result of any hazardous pursuit or pastime (for example,
aviation other than as a fare paying passenger on a regular scheduled
airline, motor racing, diving).
Page 10 of 13
Payment of claim
The life cover under this cover note becomes payable upon proof Notwithstanding any other terms under this agreement, the Company
being provided to the satisfaction of the Company of the death of the shall not be deemed to provide coverage or make any payments or
proposed life to be insured or one of the joint lives to be insured. provide any service or benefit to any insured or other party to the
Payment will be by a single lump sum in the currency and location extent that such cover, payment, service, benefit and/or any business
stipulated by the representative of the life insured’s estate, or, if or activity of the insured would violate any applicable trade or
applicable, to the beneficiary named in an appropriate beneficiary economic sanctions law or regulation.
nomination form lodged with Zurich International Life Limited.
Registered office: Zurich House, Isle of Man Business Park, Douglas, Isle of Man, IM2 2QZ, British Isles.
MSP10044 (134174018) (07/20) CMS

Page 11 of 13
‫‪DocuSign Envelope ID: B1ACA8F2-64E7-4970-9775-6D0B9DBDAEA3‬‬
‫اﻧﺗرﻧﺎﺷﯾوﻧﺎل ﺗﯾرم اﻧﺷوراﻧس‬

‫أﺣﻛﺎم وﺷروط اﻟﺗﺄﻣﯾن اﻟﻣؤﻗت ﻋﻠﻰ اﻟﺣﯾﺎة‬
‫اﻻﺳﺗﺛﻧﺎءات‬ ‫اﻟﺷروط اﻟﻣؤھﻠﺔ‬

‫اﻟرﻏم ﻣﻣﺎ ﺗﻘدم ﻓﺈن ﻋﻘد اﻟﺗﺄﻣﯾن اﻟﻣؤﻗت ھذا ﻟن ﯾﻛون ﺳﺎرﯾﺎ إذا‪:‬‬ ‫)أ( ﯾﺟب ﺗﻘدﯾم اﻟدﻓﻊ أو ﺗﻌﻠﯾﻣﺎت اﻟدﻓﻊ ﻣﻊ ﻧﻣوذج اﻟطﻠب ﺑﻘﯾﻣﺔ اﻟﺣد اﻷدﻧﻰ ﻟﻠﻘﺳط اﻟﻌﺎدي اﻻﺑﺗداﺋﻲ‬
‫ﻣﺳﺗﺣق اﻟدﻓﻊ ﺑﻣوﺟب‪.‬‬
‫)أ( ﺗم ﺗﻐﯾﯾره أو ﺗﻌدﯾﻠﮭ ﺑﺄي ﺷﻛل ﻣن اﻷﺷﻛﺎل؛‬
‫)ب( ﯾﺟب أﻻ ﯾﺗﺟﺎوز ﻋﻣر اﻟﺷﺧص اﻟﻣﻘﺗرح أو اﻷﺷﺧﺎص اﻟﻣﻘﺗرﺣﯾن اﻟذﯾن ﺳﯾؤﻣن ﻋﻠﯾﮭم ‪74‬‬
‫)ب( إذا ﻟم ﯾﺗم اﻻﻟﺗزام ﺑﺎﻟدﻓﻊ ﻓﯾﻣﺎ ﯾﺗﻌﻠق ﺑﺎﻟﻘﺳط اﻻﺑﺗداﺋﻲ ﺑﻣوﺟب اﻟﺑوﻟﯾﺻﺔ ﻓﻲ أول ﺗﻘدﯾم ﻟﻠدﻓﻊ؛‬ ‫ﻋﺎﻣﺎ ﯾﺗم ﺑﻠوﻏﮭﺎ ﻓﻲ ﺗﺎرﯾﺦ إﺻدار ﻋﻘد اﻟﺗﺄﻣﯾن اﻟﻣؤﻗت ھذا ‪.‬‬
‫)ج( وﺟود أي ﺗﺷوﯾﮭ ﻣﺎدي ﻓﻲ ﻋﻘد اﻟﺗﺄﻣﯾن اﻟﻣؤﻗت ھذا أو ﻧﻣوذج اﻟطﻠب أو أي ﻧﻣﺎذج ﺗﻛﻣﯾﻠﯾﺔ‬
‫أﺧرى؛‬ ‫اﻟﺗﺄﻣﯾن ﻋﻠﻰ اﻟﺣﯾﺎة‬
‫)د( وﻓﺎة اﻟﺷﺧص اﻟﻣﻘﺗرح اﻟﺗﺄﻣﯾن ﻋﻠﯾﮭ ﺧﻼل اﻟﻔﺗرة اﻟﺗﻐطﯾﺔ ﻋن طرﯾق اﻻﻧﺗﺣﺎر؛‬ ‫ﻣﺑﻠﻎ اﻟﺗﺄﻣﯾن ﻋﻠﻰ اﻟﺣﯾﺎة اﻟذي ﯾﻘدﻣﮭ ﻋﻘد اﻟﺗﺄﻣﯾن اﻟﻣؤﻗت ھذا ھو اﻷﻗل ﻣن ﺑﯾن ﻣﺑﻠﻎ ﻣزﯾﺔ اﻟﺗﺄﻣﯾن‬
‫ﻋﻠﻰ اﻟﺣﯾﺎة اﻟﺗﻲ ﯾﻘدم ﺑﺷﺄﻧﮭﺎ ﺑطﻠب ﺑﻣوﺟب ﻧﻣوذج اﻟطﻠب أو ‪ 250000‬دوﻻر أﻣرﯾﻛﻲ‪ .‬وﯾﺗﻌﻠق‬
‫)ه( ﺗم ﺗﺷﺧﯾص إﺻﺎﺑﺔ اﻟﺷﺧص اﻟﻣﻘﺗرح اﻟﺗﺄﻣﯾن ﻋﻠﻰ ﺣﯾﺎﺗﮭ ﺧﻼل اﻟﺳﻧوات اﻟﺧﻣس اﻟﻣﺎﺿﯾﺔ أو ﺗم‬ ‫ﻋﻘد اﻟﺗﺄﻣﯾن اﻟﻣؤﻗت ھذا ﺑﻣزﯾﺔ اﻟﺗﺄﻣﯾن ﻋﻠﻰ اﻟﺣﯾﺎة اﻟﻣﻘدم ﺑﺷﺄﻧﮭﺎ طﻠب ﻓﻘط‪ ،‬وﻻ ﯾﻧطﺑق ﻋﻠﻰ أي‬
‫ﻋﻼﺟﮭ ﺑواﺳطﺔ طﺑﯾب أو أﺧﺻﺎﺋﻲ طﺑﻲ ﻣن اﻟﺗﺎﻟﻲ‪:‬‬ ‫ﻣزﯾﺔ أﺧرى‪ ،‬أو طﻠﺑﺎت ﺗﻛﻣﯾﻠﯾﺔ أﺧرى‪ ،‬أو ﺑواﻟص إﺿﺎﻓﯾﺔ أو ﺑدﯾﻠﺔ ﺗم ﺗﻘدﯾم طﻠب ﺑﺷﺄﻧﮭﺎ‪.‬‬
‫ﺳرطﺎن‪ ،‬أو أي ورم أو ﻧﻣو ﺧﺑﯾث ﺑﻣﺎ ﻓﻲ ذﻟك ﺳرطﺎن اﻟﺟﻠد‪ ،‬أو اﻟذﺑﺣﺔ اﻟﺻدرﯾﺔ‪ ،‬أو اﻟﺳﻛﺗﺔ‬ ‫ﻓﺗرة اﻟﺗﻐطﯾﺔ‬
‫اﻟﻘﻠﺑﯾﺔ‪ ،‬أو ﻣرض اﻟﺷرﯾﺎن اﻟﺗﺎﺟﻲ أو ﺟراﺣﺔ اﻟﻘﻠب أو اﻟﻣﺦ‪ ،‬أو اﻟﺳﻛﺗﺔ اﻟدﻣﺎﻏﯾﺔ‪ ،‬أو ﻣرض‬
‫اﻟﺳﻛري‪ ،‬أو اﻟذھﺎن أو أي ﺷﻛل آﺧر ﻣن أﺷﻛﺎل اﻟﻣرض‪ ،‬أو إدﻣﺎن اﻟﻛﺣول أو إدﻣﺎن اﻟﻣﺧدرات ‪،‬‬ ‫ﯾﺳري ﻋﻘد اﻟﺗﺄﻣﯾن اﻟﻣؤﻗت ﻣن ﺗﺎرﯾﺦ ﺗﻠﻘﻲ زﯾورﯾﺦ إﻧﺗرﻧﺎﺷﯾوﻧﺎل ﻻﯾف ﻟﯾﻣﯾﺗد )واﻟذي ﯾﺷﺎر اﻟﯾﮭﺎ‬
‫أو ﻣرض اﻟﻌوز اﻟﻣﻧﺎﻋﻲ اﻟﻣﻛﺗﺳب )اﻹﯾدز(‪ ،‬أو ﻋدوى ﻓﯾروس ﻧﻘص اﻟﻣﻧﺎﻋﺔ اﻟﺑﺷرﯾﺔ‪ ،‬أو أي‬ ‫ﻻﺣﻘﺎ ﺑـ “اﻟﺷرﻛﺔ”( ﻧﻣوذج طﻠب ﻣﻌﺑﺄ ﺑﺎﻟﻛﺎﻣل‪ ،‬ﺑﺎﻟﺗزاﻣن ﻣﻊ أول ﻗﺳط أو ﺗﻌﻠﯾﻣﺎت دﻓﻊ ﺳﺎرﯾﺔ ﺣﺗﻰ‬
‫ﻣرض أو ﺣﺎﻟﺔ ﻋﺟز أﺧرى؛‬ ‫اﻷﺳﺑق ﻣن اﻟﺗوارﯾﺦ اﻟﺗﺎﻟﯾﺔ‪:‬‬
‫)و( ﺳﺑق رﻓض اﻟﺷﺧص اﻟﻣﻘﺗرح اﻟﺗﺄﻣﯾن ﻋﻠﯾﮭ أو ﺗﺄﺟﯾﻠﮭ أو ﻗﺑوﻟﮭ ﺑﺷروط ﺧﺎﺻﺔ ﻟﻠﺗﺄﻣﯾن ﻋﻠﻰ‬ ‫)أ( ﯾﺻﺑﺢ ﺗﺎرﯾﺦ اﻟﺑوﻟﯾﺻﺔ ﻧﺎﻓذا‬
‫اﻟﺣﯾﺎة ﻓﻲ اﻟﻣﺎﺿﻲ؛‬
‫)ب( ﻋﻧد ﻣﻧﺗﺻف اﻟﻠﯾل )ﺑﺎﻟﺗوﻗﯾت اﻟﻣﺣﻠﻲ( ﻓﻲ اﻟﯾوم اﻟﺳﺗﯾن )‪) 60‬ﺑﻌد ﺑدء اﻟﺧطر ﺑﻣوﺟب ﻋﻘد‬
‫)ز( ﺗﺣدث اﻟوﻓﺎة أو اﻻﺧﺗﻔﺎء ﻣﺑﺎﺷرة ﺑﺳﺑب أو ﻧﺗﯾﺟﺔ أي ﺷﻛل ﻣن اﻷﺷﻛﺎل اﻟﻣﺗﻌﻠﻘﺔ ﺑﻣﺎ ﯾﻠﻲ‪:‬‬ ‫اﻟﺗﺄﻣﯾن اﻟﻣوﻗت ھذا ‪.‬‬
‫)أو ﻻ( اﻟﺣرب أو اﻟﻌﻣﻠﯾﺎت اﻟﺣرﺑﯾﺔ )ﺳواء أﻋﻠﻧت اﻟﺣرب أم ﻻ( ﺑﻣﺎ ﻓﻲ ذﻟك ﻏزو أو أﻋﻣﺎل ﻋدو‬ ‫)ج( ﺗﺎرﯾﺦ إﺻدار إﺷﻌﺎر ﻣن ﻗﺑل اﻟﺷرﻛﺔ ﺑرﻓض اﻟﺗﻐطﯾﺔ أو ﺑﺗﺄﺟﯾﻠﮭ أو ﺑﺗﻘدﯾم ﻋرض ﻣﺗﻘﺎﺑل ‪.‬‬
‫أﺟﻧﺑﻲ أو أﻋﻣﺎل ﻋداﺋﯾﺔ أو ﺗﻣرد أو ﺷﻐب أو اﺿطراﺑﺎت ﻣدﻧﯾﺔ أو ﻋﺻﯾﺎن أو ﻋﺻﯾﺎن ﻣﺳﻠﺢ أو‬
‫ﺣرب أھﻠﯾﺔ أو ﺗﺂﻣر أو ﻗوة ﻋﺳﻛرﯾﺔ أو ﻣﻐﺗﺻﺑﺔ أو أﺣﻛﺎم ﻋرﻓﯾﺔ أو ﺣﺎﻟﺔ ﺣﺻﺎر‪ ،‬أو أي ﻣن‬ ‫ﻋﻧدﻣﺎ ﯾﻛون اﻟطﻠب ﺧﺎﺻﺎ ﺑﺑوﻟﯾﺻﺔ ﺗﺄﻣﯾن ﻋﻠﻰ اﻟﺣﯾﺎة ﻣﺷﺗرﻛﺔ وﺗوﻓﻲ أﺣد اﻷﺷﺧﺎص اﻟﻣﻘﺗرح‬
‫اﻷﺣداث أو اﻷﺳﺑﺎب اﻟﺗﻲ‬ ‫اﻟﺗﺄﻣﯾن ﻋﻠﻰ ﺣﯾﺎﺗﮭم أﺛﻧﺎء ﻓﺗرة اﻟﺗﺄﻣﯾن ﻋﻠﻰ اﻟﺣﯾﺎة اﻋﺗﺑﺎرا ﻣن ﺗﺎرﯾﺦ اﻟﻣؤﻗﺗﺔ‪ ،‬ﺳوف ﯾﺗم إﻟﻐﺎء‬
‫اﻟﺗﻐطﯾﺔ ﻋﻠﻰ اﻟﺣﯾﺎة اﻷﺧرى وﻓﺎة اﻟﻣؤﻣن ﻋﻠﻰ ﺣﯾﺎﺗﮭ اﻟﻣﺗوﻓﻰ‪ .‬وإذا ﻛﺎن ﻣﻧﺎﺳﺑﺎ ‪ ،‬ﺳوف ﯾﺗم ﺑﻌد ذﻟك‬
‫ﺗﺣدد إﻋﻼن أو ﻣواﺻﻠﺔ اﻷﺣﻛﺎم اﻟﻌرﻓﯾﺔ أو ﺣﺎﻟﺔ ﺣﺻﺎر؛‬ ‫طﻠب ﻧﻣوذج طﻠب ﺟدﯾد ﻣن اﻟﻣؤﻣن اﻟذي ﻣﺎ زال ﻋﻠﻰ ﻗﯾد اﻟﺣﯾﺎة‪.‬‬
‫)ﺛﺎﻧﯾﺎ ( أﻋﻣﺎل اﻹرھﺎب ﺑﻣﺎ ﻓﻲ ذﻟك أي ﻓﻌل أو ﻧﺷﺎط ذي ﺻﻠﺔ ﯾﺷﻛل ﺧطورة ﻋﻠﻰ ﺣﯾﺎة اﻹﻧﺳﺎن أو‬
‫ﻣﻣﺗﻠﻛﺎﺗﮭ‪ ،‬ﺳواء ﺗم ﺗﻘدﯾم طﻠب ﺑﺷﺄﻧﮭﺎ أم ﻻ‪.‬‬
‫)ح( ﺣدوث وﻓﺎة ﻟﺷﺧص ﻣﻘﺗرح اﻟﺗﺄﻣﯾن ﻋﻠﯾﮭ ﻣﺑﺎﺷرة أو ﻏﯾر ﻣﺑﺎﺷرة ﻧﺗﯾﺟﺔ ﻷي ﻣﻣﺎرﺳﺔ أو ھواﯾﺔ‬
‫ﺧطرة )ﻋﻠﻰ ﺳﺑﯾل اﻟﻣﺛﺎل‪ ،‬اﻟطﯾران ﺑﺧﻼف راﻛب ﯾدﻓﻊ أﺟرة ﻋﻠﻰ ﺧط اﻟﺟوﯾﺔ ﻣﻧﺗظﻣﺔ ﻣﺣددة‬
‫اﻟﻣواﻋﯾد‪ ،‬أو ﺳﺑﺎﻗﺎت اﻟﺳﯾﺎرات‪ ،‬أو اﻟﻐوص(‪.‬‬
‫اﻟرﺟﺎء اﻟرﺟوع إﻟﻰ ﺷروط وأﺣﻛﺎم اﻟﺑوﻟﯾﺻﺔ ﻟﻼطﻼع ﻋﻠﻰ اﻟﺗﻔﺎﺻﯾل اﻟﻛﺎﻣﻠﺔ ﻟﻼﺳﺗﺛﻧﺎءات‪.‬‬
‫‪Page 12 of 13‬‬
‫‪DocuSign Envelope ID: B1ACA8F2-64E7-4970-9775-6D0B9DBDAEA3‬‬
‫دﻓﻊ اﻟﻣطﺎﻟﺑﺔ‬
‫ﺑﺻرف اﻟﻧظر ﻋن أي ﺷروط أﺧرى ﺑﻣوﺟب ھذا اﻻﺗﻔﺎق‪ ،‬ﻻ ﯾﻔﺗرض ﻗﯾﺎم اﻟﺷرﻛﺔ ﺑﺗوﻓﯾر اﻟﺗﻐطﯾﺔ‬ ‫ﯾﺻﺑﺢ اﻟﺗﺄﻣﯾن ﻋﻠﻰ اﻟﺣﯾﺎة ﺑﻣوﺟب ﻋﻘد اﻟﺗﺄﻣﯾن اﻟﻣؤﻗت ھذا ﻣﺳﺗﺣق اﻟدﻓﻊ ﻋﻧد ﺗﻘدﯾم دﻟﯾل ﯾرﺿﻲ‬
‫أو ﺗﻘدﯾم أي ﻣﺑﺎﻟﻎ أو ﺗﻘدﯾم أي ﺧدﻣﺔ أو ﻣﯾزة ﻷي طرف ﻣؤﻣن ﻋﻠﯾﮭ أو طرف ﻏﯾره إﻟﻰ ﺣد اﻧﺗﮭﺎك‬ ‫اﻟﺷرﻛﺔ ﺑوﻓﺎة اﻟﺷﺧص اﻟﻣﻘﺗرح اﻟﺗﺄﻣﯾن ﻋﻠﯾﮭ أو أﺣد اﻷﺷﺧﺎص اﻟﻣﺷﺗرﻛﯾن اﻟذﯾن ﺳﯾﺗم اﻟﺗﺄﻣﯾن‬
‫ھذه اﻟﺗﻐطﯾﺔ و‪/‬أو اﻟدﻓﻊ و‪/‬أو اﻟﺧدﻣﺔ و‪/‬أو اﻟﻣﯾزة و‪/‬أو أي‬ ‫ﻋﻠﯾﮭم‪ .‬وﺳوف ﯾﻛون اﻟدﻓﻊ ﻋن طرﯾق ﻣﺑﻠﻎ إﺟﻣﺎﻟﻲ ﺑﺎﻟﻌﻣﻠﺔ وﻓﻲ اﻟﻣﻛﺎن اﻟﻣﻧﺻوص ﻋﻠﯾﮭﻣﺎ ﺑواﺳطﺔ‬
‫ﻋﻣل أو ﻧﺷﺎط ﻟﻠﻣؤﻣن ﻋﻠﯾﮭ ﻷي ﻗواﻧﯾن أو ﻟواﺋﺢ ﻋﻘوﺑﺎت ﺗﺟﺎرﯾﺔ أو اﻗﺗﺻﺎدﯾﺔ ﻣﻌﻣول ﺑﮭﺎ‪.‬‬ ‫ﻣﻣﺛل ﺗرﻛﺔ اﻟﻣؤﻣن ﻋﻠﻰ ﺣﯾﺎﺗﮭ‪ ،‬أو ﻋﻧد اﻻﻗﺗﺿﺎء‪ ،‬إﻟﻰ اﻟﻣﺳﺗﻔﯾد اﻟﻣذﻛور ﻓﻲ ﻧﻣوذج ﺗرﺷﯾﺢ‬
‫ﻣﺳﺗﻔﯾد ﻣﻧﺎﺳب ﻣودع ﻟدى زﯾورﯾﺦ إﻧﺗرﻧﺎﺷﯾوﻧﺎل ﻻﯾف ﻟﯾﻣﯾﺗد‪.‬‬
‫زﯾورﯾﺦ اﻧﺗرﻧﺎﺷﯾوﻧﺎل ﻻﯾف ﻟﯾﻣﺗد ﻣﺳﺟﻠﺔ ﺑﻣوﺟب اﻟﻘﺎﻧون اﻻﺗﺣﺎدي رﻗم ‪ 6‬ﻟﺳﻧﺔ ‪ 2007‬ﻟدوﻟﺔ اﻹﻣﺎرات اﻟﻌرﺑﯾﺔ اﻟﻣﺗﺣدة )رﻗم اﻟﺗﺳﺟﯾل ‪) 63‬وﺗﺧﺿﻊ أﻧﺷطﺗﮭﺎ ﻓﻲ‬
‫اﻹﻣﺎرات اﻟﻌرﺑﯾﺔ اﻟﻣﺗﺣدة ﻟﮭذا اﻟﻘﺎﻧون‪.‬‬
‫زﯾورﯾﺦ اﻧﺗرﻧﺎﺷﯾوﻧﺎل ﻻﯾف ھو اﺳم ﺗﺟﺎري ﻟزﯾورﯾﺦ اﻧﺗرﻧﺎﺷﯾوﻧﺎل ﻻﯾف ﻟﯾﻣﺗد واﻟﺗﻲ ﺗﻘدم ﻣﻧﺗﺟﺎت ﺗﺄﻣﯾن ﻋﻠﻰ اﻟﺣﯾﺎة واﺳﺗﺛﻣﺎر وﺣﻣﺎﯾﺔ‪ ،‬وھﻲ ﻣﻔوﺿﺔ ﻣن ﻗﺑل ھﯾﺋﺔ‬
‫اﻟﺧدﻣﺎت اﻟﻣﺎﻟﯾﺔ ﻓﻲ آﯾل أوف ﻣﺎن‪.‬‬
‫ﻣﺳﺟﻠﺔ ﻓﻲ ﺟزﯾرة ﻣﺎن ﺑرﻗم ‪.20126C‬‬
‫اﻟﻣﻛﺗب اﻟﻣﺳﺟل‪ :‬زﯾورﯾﺦ ھﺎوس‪ ،‬أﯾل أوف ﻣﺎن ﺑزﻧس ﺑﺎرك‪ ،‬دوﻏﻼس‪ ،‬آﯾل اوف ﻣﺎن‪ ،‬آي إم ‪ 22‬ﻛﯾو زد‪ ،‬اﻟﺟزر اﻟﺑرﯾطﺎﻧﯾﺔ‪.‬‬
‫ﺗﻠﯾﻔﺎﻛس ‪ + 44 1624 662038‬اﻟﮭﺎﺗف ‪www.zurichinternational.com +44 1624 662038‬‬
‫‪MSP10044 (134174018) (07/20) CMS‬‬

‫‪Page 13 of 13‬‬
Policy owner(s) declaration
I/We declare that I/we have met the financial professional in person or virtually and that no third parties have been involved in providing the
advice or the collection/certification of my/our due diligence documentation (where applicable) at any stage of the policy application process.
Signature of policy owner 1
\PO1\

\PO1D\
Date 07-Sep-2022 | 10:16:15 ARBST
Zurich International Life Limited is registered in Bahrain under Commercial Registration No. 17444 and is licensed as an
Overseas Insurance Firm – Life Insurance by the Central Bank of Bahrain
Zurich International Life Limited is authorised by the Qatar Financial Centre Regulatory Authority
Registered office: Zurich House, Isle of Man Business Park, Douglas, Isle of Man, IM2 2QZ British Isles.
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DocuSign Envelope ID: B1ACA8F2-64E7-4970-9775-6D0B9DBDAEA3

International Term Assurance

Agency number 8920001

Bank/Broker name ADCB (DST&MRT&INV&EUL)

External reference number NIL

1 Policy owner(s) details

First name MANMOHAN

Family name BANSAL

Date of birth 1 January 1975

Occupation Business Owner

Country of birth India

Dual nationality (if applicable) N.A.

Flat/villa number FLAT NO.: 706

Property/building name Fathima Ali Owais

Country United Arab Emirates

Policy owner(s) details(continued)

P.O. Box number N.A.

Mobile number (include international country code)

Telephone number (optional)

Email address nribanking75@gmail.com

Are you a politically exposed person? No

2 Life/Lives Insured Details

Family Name BANSAL

Date of birth 1 January 1975

Occupation Business Owner

Current Residential address

Flat/villa number FLAT NO.: 706

Property/building name Fathima Ali Owais

Country United Arab Emirates

Life/Lives to be insured (continued)

P.O. Box number N.A.

Telephone number N.A.

Mobile number +971 525192145

Email address nribanking75@gmail.com

Policy Currency USD

Premium Amount 154.30 (in policy currency)

Premium Frequency Monthly

Please state the amount of cover required in the policy currency.

Compulsory beneﬁts: Amount

Life Cover 100,000

Critical illness beneﬁt 100,000

Permanent and total disability beneﬁt 100,000

Waiver of premium beneﬁt Life insured 1 Yes Life insured 2 N.A.

a) Passport copy – including signature page and residence visa (expats)

b) Government issued identity card (both sides)

Job Title INVESTOR

Would you like this policy to replace an existing Zurich plan? No

7 Request for conditional assignment

First Name RIYANSH

Family Name BANSAL

Date of Birth 7 January 2013

Relationship to life insured SON

Flat/villa number FLAT NO.: 706

Building/property name Fathima Ali Owais

Country United Arab Emirates

Email address nribanking75@gmail.com

Share percentage 100

9 Relevant ﬁnancial professional’s details and declaration

To be completed by your relevant ﬁnancial professional

First name Sujit Kumar Last name Pandey

Email address sujit.pandey@adcb.com

Contact number N.A.

How we transfer personal information to other countries