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  Tel.: + 962 6 4621562
+ 962 6 4637092
+ 962 6 4640008
  Fax.: + 962 6 4654631
  JABAL AMMAN 1ST CIRCLE – ASTRA BLDG. 3RD FLOOR
  P.O.Box: 3055 Amman
11181 Jordan
  E-mail: info@delta-ins.com
  Travel Insurance
     
  Global Travel Insurance cover:  
 
  • Worldwide Emergency Medical Expenses & Hospitalization Abroad.
     
  • Accidental Death or Permanent Disability.
     
  • Cover required by European Embassies to acquire Schengen visas.
  
 

Do not ask for expenses                         
ask for the cover & Protection
 
     
  MEDICAL AND TRAVEL ASSISTANCE APPLICATION FORM  
 
   
 

Insured :

Occupation :

Marital Status :

Married Single

Sex :

Male     Female

Nationality :

I.D. No :

National I.D. No. :

Date of Birth :

Address :

Tel. No. :

Period Of Insurance from :

To

Geographical area :

Beneficiary :

  Please answer the following questions:

1- Have you ever been diagnosed or received any treatment (including hospital or surgery) or felt any disorder or pain or had any symptoms indicating:
Heart disease, High blood Pressure, Diabetes, Congenital Anomalies and diseases, Cancer, Mental disorders and nervous disease, Aids, Back pain and any other diseases, symptoms and complaints not mentioned above.
Yes
No
 

2- You have any physical disability

Yes
No
   

3- Have you ever got involved or are planning to be involved in a dangerous sport or hobby
Yes
No
   

4- Do you have other residency

Yes
No

5- Do you have any other nationality
Yes
No
   
* NOTE: If answer is yes to any of the questions above please specify the name and write down full details:
 

 


I the undersigned declare that I have noticed all the general conditions of insurance and that I agree to it and that all the details information and answers in this application are true and that I agree that this declaration and answers given be the basis of contract between me and Delta Insurance Co./Amman and this insurance will not be valid until the contract of insurance is issued and delivered to me.
Any wrong information in this application will effect basically in the acceptance of this application and releases the company from any liability under this contract.
I also authorize any doctor, hospital, clinic, insurance company or any other company or organization or person who has any information about me to give Delta Insurance Co. all the information relating to my health, medical history, advice, treatment, illness or car accident . The photocopy of this declaration is considered true and good for the above reasons as if it was the original copy.
 
  Signed In ……………… On ……………………
Signature …………………….

 
     
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