ONLINE APPLICATION FORM
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FAQ
For Medical and Personal Accident
Please fill the following online form to provide an insurance coverage for your LOVED ONES. For further information see
details
or contact our
agents.
From: (Sponsor's particulars)
Full Name
*
Country
*
State
*
City/town
*
E-mail
*
Tel
*
Fax
Select your Agent
*
Ezra Teshome
Zecharias Getahachw
Teferawork Assefa
I would like to buy the following Insurance policies for my:
Medical +
Personal Accident
Select benefit limit
5,000 + 5,000 birr
10,000 + 10,000 birr
15,000 + 15,000 birr
see details >>
Annual Flat Premium in USD =
per individual
Others
See Other Products
Auto
Others
-------
MONEY INSURANCE
BURGLARY INSURANCE
FIDELITY INSURANCE
ENGINEERING INSURANCE
MARINE INSURANCE
Fire
Property Insurance
Life
The clients particulars in Ethiopia:
FULL NAME
*
CITY/TOWN
*
WEREDA
KEBELE
HOUSE NO.
TEL
*
FAX
E-MAIL
* = Required fields
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