Members Group Insurance Scheme – CONSENT FORM
St.Gregorios Orthodox Church. Sharjah

Church Group Life Insurance – Already in existence - coverage for accidental / natural death for the insured. (Eligibility Age Group 3 to 65) - (Approx. Cost – AED 40 – 50)

Church Group Health Insurance – Coverage for Medical Expenses (Approx. Cost – AED 900 – 1,300).

To be implemented as per the approval of General body.

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Email *
Church Membership No. *
Use format X-123
Church Area *
Mobile No. *
Details for Member & Dependent
Consent to be hereby given to enroll, by selecting the below insurance scheme
Member Name *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Visa - Emirate *
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Required
Dependent-1 Name
Date of Birth
MM
/
DD
/
YYYY
Gender
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Visa - Emirate
Please Tick
Dependent-2 Name
Date of Birth
MM
/
DD
/
YYYY
Gender
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Visa - Emirate
Please Tick
Dependent-3 Name
Date of Birth
MM
/
DD
/
YYYY
Gender
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Visa - Emirate
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Dependent-4 Name
Date of Birth
MM
/
DD
/
YYYY
Gender
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Visa - Emirate
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Dependent-5 Name
Date of Birth
MM
/
DD
/
YYYY
Gender
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Visa - Emirate
Please Tick
Dependent-6 Name
Date of Birth
MM
/
DD
/
YYYY
Gender
Clear selection
Visa - Emirate
Please Tick
Disclaimer:
The personal data collected through the consent forms is to be used only for the purpose for evaluating /
doing a preliminary study of launching the above said insurance schemes in our church.
A copy of your responses will be emailed to the address you provided.
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