Membership Application Form

Company Details

Name

Country

Tel

Fax

Email

Website

Postal Address

Working Days

From

To

Working Hours

From

To

Top Management

Name

Position

Tel

Mobile

Fax

Email

International Department

Name

Position

Tel

Mobile

Fax

Email

Establishment Date

    

    

License

Date of Issue

Number

Professional Indemnity Insurance

Sum Insured

Period

Activity

Direct Broker

Reinsurance Broker Consultant

Class of Business

Life Non-Life Composite

Takaful

Company Capital (National Currency)

Authorized

Issued

Paid Up

Ownership

% National Entities/Individuals

% Others from Afro-Asian Countries

% Others from Non Afro-Asian Countries