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Income Protection Insurance (Claim Form)

Please click the following button to download the claim form and submit it offline. Download Claim Form

To be completed by the Life Insured or Claimant in BLOCK letters.
Please answer all questions, use "not applicable" (N/A) as appropriate instead of leaving it blank. Counter-sign where amendments/alterations are made in the form.
The filing of this claim form is not to be construed as an admission of liabilities by the Company.
Please click here to see the documents that are required to make a claim.

Policy Holder Details

Policy Number

Name of Policy Holder

Passport No of Policy Holder:

UAE Visa No of Policy Holder

Nationality of Policy Holder

Date of Birth of Policy Holder:

Name of the Claimant:

Age of the Claimant:

Contact number of the Claimant::

Relationship with the Policy Holder:

Passport No of Claimant

UAE Visa No of Claimant

Nationality of Claimant

Claim Details

Type of Claim :

Accidental Death

Hospital Cash

Involuntary Loss Of Employment(ILOE)

Accidental Death Amount

Hospital Cash Amount

ILOE Amount

Date of Event

Description of the claim

Please explain your claim details Please refer to the required list of documents to support your claim

Accidental Death

Date of Death

Place of Death

Cause of Death:

Road Traffic

Accidental Fall

Drowning

Fire Related

Industrial

Accident

Others (Please provide Details).

Hospital Cash

Type of Illness

Name and Address of treating doctor

Hospital contact number

Hospital email Address:

Number of days in Hospital:

Date of Discharge

Other Discharge Details

Details of Illness

Involuntary Loss of Employment

Name and Address of Employer

Occupation

Employer contact number

Employer email Address

ILOE Start Date

Date of Termination

Reason for Termination

I hereby confirm that I have been terminated from my employment as of date of termination mentioned above and I am currently not employed. I undertake that I will inform Orient Insurance PJSC immediately should I be re-employed.

I am aware and acknowledge that the ILOE claim will discontinue once I am re-employed

Authorization: I hereby authorize any physician, hospital, insurer/medical information bureau or other organization or person having any records, data or information as may be requested by Orient Insurance or their representative. I understand that in executing this authorization, I waiver the right for such information to be privileged. A Photocopy or scanned copy of this authorization shall be considered as effective and valid as original

Upload Documents (Passport copy, Emirates ID etc. Maximum Size allowed = 2 MB, Formats allowed = pdf, jpg, jpeg, png, gif, tif.)

Declaration: I declare that the information given above is, to the best of my knowledge and belief, true and complete.

Orient Insurance PJSC

Orient Building | Al Badia Business Park | Dubai Festival City PO Box 27966, Dubai, UAE
TOLL FREE 800-ORIENT (674368)
orient.services@alfuttaim.ae