Mastercard Offers – Ceylinco Dengue Chikungunya Cover

Dependents

Name

Date of Birth

NIC/ Passport No

Relationship

I/We submit herewith a schedule which indicates the details, as per No.5 of all members to be covered by this Policy. I/We agree that this proposal, declaration and the completeness herein, shall be the basis of the contract between us and Ceylinco General Insurance Limited. If the details provided by us cease to be true or complete, we undertake to give immediate written notification to the Company. We further agree to accept the usual form of certificate/policy issued by the Company, subject to the terms and conditions therein contained.