Supplemental Insurance Registration Select Plan(Required)30% Plan10% PlanPersonnel Code(Required)First Name(Required)Last Name(Required)Father’s Name(Required)Date of Birth(Required) YYYY slash MM slash DD Gender(Required)MaleFemaleOtherMarital Status(Required)SingleMarriedOtherNational ID Number(Required)Birth Certificate Number(Required)Phone Number(Required)Mobile Number(Required)Relationship to Primary Insured(Required)Primary insuredSpouseFatherMotherSonDuaghterDependence Status(Required)DependentNon-dependentPrimary InsuredBasic Insurance Type(Required)Social SecurityHealth InsuranceMedical Services InsuranceImam Khomeini Relief Committee (IKRC)Bank Mellat Account Number(Required)Bank Mellat IBAN(Required)Account Type(Required)Qarz-al-Hasanah (Interest-Free Account)Short-TermLong-TermQarz-al-Hasanah Savings AccountUnspecified / UnknownAccount Holder Name(Required)Primary Insured’s Full Name(Required)Primary Insured’s National ID Number(Required)
