Insurance Request

Organization Name Requesting Insurance
Business Activity of the Requesting Organization
Type of Service Requested
Beneficiaries
Employee
Spouse
Children
Parents
Requested Coverage Benefits
Internal Treatments
External Treatments
Dental
Eyeglasses
Chronic Diseases
Pregnancy and Childbirth
Travel Abroad
Other Benefits

General Information

Will the treatment costs be deducted from the employee's salary, or will the organization bear the full treatment costs?
If the deduction is from the employee's salary, please specify the deduction percentage
Did you have insurance with another company before?
If yes, please provide the name of the previous company and the year of the insurance coverage
Please specify the coverage locations for the medical network and branch centers in the governorates
Applicant's Name
Mobile Number

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