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Freedom Security
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Insured event
7775
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Insured event
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7775
Freedom Income
REGISTRATION
Manager identification number:
Manager identification number:
Manager fullname:
Manager fullname:
Who will we insure/the policyholder?
Enter IIN
Enter IIN
Enter your full name
Enter your full name
Gender
Gender
Date of birth
Date of birth
Phone
Phone
Email to receive the policy:
Email to receive the policy:
Residence address: street, house, apt.
Residence address: street, house, apt.
Document, identifying a person
Document type
Document type
Document number
Document number
Date of issue of the document
Date of issue of the document
Issuing Authority
Issuing Authority
Beneficiary
Enter IIN
Enter IIN
Enter your full name
Enter your full name
Gender
Gender
Date of birth
Date of birth
Phone
Phone
Email to receive the policy:
Email to receive the policy:
Your place of residence:
Your place of residence:
Document, identifying a person
Document type
Document type
Document number
Document number
Date of issue of the document
Date of issue of the document
Issuing Authority
Issuing Authority
Health Questionnaire
No
Yes
Are you HIV positive or have AIDS?
No
Yes
Are you HIV positive or have AIDS?
No
Yes
Are you registered in narcological, neuropsychiatric, tuberculosis or oncological dispensaries? Are you being observed and/or receiving treatment in other medical institutions with relevant diseases?
No
Yes
Are you in the dispensary for any disease?
Insured sum and payment method
Kaspi
CSO
Insurance period, years:
3
4
5
6
7
8
9
10
3
Periodicity of premium payment:
Once
Annually
Once in a half year
Once in a quarter (3 months)
Monthly
Insured sum USD:
Insured sum USD:
Insurance premium USD:
Insurance premium USD:
To pay KZT:
To pay KZT:
I confirm compliance and consent with the terms
of declarations
I give my consent for collection and processing of personal data and I am familiar with the
insurance rules
Pay
