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Review Details
Your quotation is under referral criteria , you may
submit the quote to Orient
PRODUCT DMED LSB WITH SALARY UPTO 4000
Policy Details
Quotation MED/2023/101211 Product DMed
No
Policy No Issue 17/04/2023
Date 12:18:00
Policy 17/04/2023 Policy 16/04/2024
From 12:45:51 To Date 23:59:00
date
DMED- Yes
LSB
Insured Details
Insured Rayan mohamed Gender MALE
Name zaghloul samir
Date Of 12/06/2021 Email mohamedz
Birth
Mobile No 971544104804 Marital Single
Status
Sponsor Children (Other Passport A28494601
Relationship than Married No
Females)
EmiratesID 784-2021- EmiratesID 27/03/2025
No 2794285-6 Expiry
Date
UID No 784202127942856 Nationality Egypt
Country Of United Arab Country Of UAE
Origin Emirates Residence
Emirates Of Fujairah Sub- Dibba
Residence region
Residence Dubai Do you Yes
Visa Place hold Dubai
Visa?
Chronic No Critical No
Conditions Cases
Pregnancy No Height(in 73 / 13
Yes/No Cm) /
Weight (in
Kg)
Member 4 Member ID I008-002-11
Type
Uploaded to No Medical
TPA Y/N Card
Number
Sponsor Details
Sponsor Mohamed Samir ali Sponsor
Name Number(UI
Sponsor Resident No. of pers
Type holding a v
under this
employer/s
No. of 0 No. of othe
Lower employees
band
salary
employees
Work Mohamedzaglol2001@gmail.com Landline N
Email Id
Premium
AED 588.85
File Uploads for Insured
Passport
EmiratesID
Visa
Passport Size Photo
File Uploads for Sponsor
Sponsor Passport
Sponsor EmiratesID
Sponsor Visa
Sponsor Passport Size Photo
Tax Invoice in the name
Tax Invoice Name
Insured TRN No
Insured TRN No
Referral Remarks History
Sl Remarks Created Activity
No By Date
17/04/2023
1 None Guest
12:48:57
Declarations
I, the undersigned, hereby declare that I am a
resident of United Arab Emirates and all information
provided along with this application are true and I
have not withheld any material information that may
affect the proposal. I understand that this application
shall form the basis of the policy between Orient
Insurance and myself and that the policy is valid only
once the premium is paid in full. I authorize Orient to
debit my bank account/credit card for the value
shown and accept to receive the policy documents
electronically.
I understand that checking this box constitutes a
legal signature confirming that I agree to the above
terms and conditions of Orient Insurance.Any non-
disclosure / misrepresentation * or concealment of
material facts will make this policy void with
immediate effect without any entitlement for refund.
In the event, this medical application form has been
completed by someone else; I take full responsibility
of the information provided, and agree that a true
declaration has been given.
Policy will be subject to audit post policy issuance.
In order to avoid suspended/non continuity of the
service, please make sure that :
a) All information is complete
b) Correct documents are uploaded
c) All information is properly and correctly disclosed.
Notification email will be sent to the client and
respective sales channel with documents needed or
correction requested.
in case we did not receive the requirements within 14
days; policy will be cancelled without refund
* For first scheme membership
