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Provider Details

Kindly provide the details in the following box. All fields marked * are mandatory

Name of the Facility : *

Name of the Facility in Arabic :

Country : *

Emirate/City : *

Area/Region : *

P.O. Box : *

Street Address : *

Telephone : *

Fax : *

Username : *

Provider Details in Arabic

(Kindly provide the details in the following box. This is optional)

Country :

Emirate :

P.O. Box :

Area/Region* :

Street Address :

Contact details of insurance coordinator

(Kindly provide atleast one contact details in the following boxes. Fields containing * are mandatory)

Details 1
(Mandatory)
Details 2
(Optional)

Name :*

Designation : *

Telephone : *

Mobile : *

Fax : *

Insurance co-ordinator Email : *

Enter the code shown
below :*

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