Group Personal Accident Quotation

Personal Details

Proposer Type

Proposer First Name

Proposer Middle Name

Proposer Last Name

Mobile No.

Email Address

Which Berhan Insurance S.C. branch do you want to be served from?

Risk Details

Start Date

End Date

Cover Type

Please select method to Fill Employees’ Detail(s)

Last Row of Excel

Download Template

Excel

* Allowed file formats (xlsx)

Employee 1

Do you want to cover your members by group?

Estimated Annual Earnings

Emp Id

Employee Name Occupation Group Name

Member No of Member

Job Description / Occupation

Occupation Name

Monthly Salary

Death

Permanent Total Disability (PTD)

Temporary Total Disability

Medical Expenses Due to Accident

Additional Benefits:

Medical Expenses Due to Illness

Eye Frame

Eye Glass

Denture

Pregnancy

Boarding & Lodging

Extension to worldwide ?

Are you engaged in any of the activities / occupations mentioned below?

Football

Small Game hunting

Big Game Hunting

Water Skinning

Motor cycling exceeding 10cc

Auto-Cycling and mechanically assisted pedal cycles not exceeding 100cc

Mountaineering

POLO

Steeple chasing winter sports

Motor Cycling not Exceeding 10cc

Racing of any kind

Swimming

Do you want additional cover for medical expenses due to illness per family members?

Do you want to take additional extension covers commonly for the family members?

Family Member/illness Amount detail

Member Full Name

Relation

Medical expenses due to illness amount

Additional Benefits Per Family Member

Eye Frame Value

Eye Glass Vaule

Dental Vaue

Preganacy and Child Birth

Boarding and Loading

Do you want additional cover for medical expenses due to illness per family?

Do you want to take additional extension covers separately for the family members?

Commonly Additional Benefits For Family Members