Insurance Application Form
Before getting started we’d like to know about you. Please provide us the listed details in order to help you through your journey. *Customer name and the nominee name should be match during the claim
Insured Name *
Gender *
Mobile Number *
Date of Birth (DD/MM/YYYY) *
Nominee Name *
Nominee Relationship *
- I am over 18 years and less than 60 years of age.
- I am currently not receiving any treatment, have not been treated or advised to have any treatment for Cancer, HIV /AIDS, Kidney, Liver or Lungs Disorder, Brain Diseases, Heart or Blood Diseases, and I am not currently totally or partially disabled to work due to sickness or an accident and I do not have any physical impairment.
- I hereby understand and agree that no insurance benefit shall be payable by the insurance company under the policy in case of any pre-existing condition, any diagnosis of critical illnesses during the waiting period of 30 days from effective date of my individual insurance and other terms & conditions of Group Master Policy shall apply.
- I agree to share my information including Personal Information with MetLife, its Group Companies, reinsurance companies both within and outside Nepal for the purpose of insurance.
- I authorize MetLife to collect my medical information from any doctor, hospital, clinic or medical providers.
- I also declare that I understand and agree that any misstatement in this declaration will invalidate my insurance coverage from inception and no benefit shall be payable by the insurance company under this policy.
- I authorized MetLife to collect, store, protect, analyze and process my personal and sensitive information including medical history.
- I agree and acknowledge that the information provided herein above is correct, true and complete to the best of my knowledge.