Name Of the insured: *

Country of Residence: Jordan Other Country Name: E-mail:

Passport No: Nationality: National Security No: Landline Phone No : Mobile No: Occupation: select...BankingInsuranceEducationITEngineeringHotel managementAccountingMedical servicesTelecommunicationSales /MarketingPressAdvertising Date of Birth: monthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember day12345678910111213141516171819202122232425262728293031 P.O.Box :

Geographic Coverage: SCHNGN Worldwide excluding USA and Canada Worldwide including USA and Canada

Period: Yearly Short Term Years: Days :

Policy Benefits & limitations - SCHENGN countries.

Covers	limits
MEDICAL EXPENSES & HOSPITALIZATION ABROAD	30,000 Euro *
TRANSPORT OR REPARATION IN CASE ILLNESS OR ACCIDENT	Actual Expenses
REPATRIATION OF MORTAL REMAINS	Actual Expenses

Important Notice:This Insurance excludes any pre-exiting medical cases / illness occurred prior to inception of this
insurance and the date of filling the related proposal form.

I am the undersigned declare according to my best Knowledge and belief being in good health and confirm not suffering any chronic diseases and/ or taking any continuous medication and /or being admitted for inpatient treatment in the hospital during the past nine months prior to the inception date of the SCHENGN policy