1. System Generated Field Panel
2. Author Entered Field Panel
3. Form Title Panel
4. End-user Entered Field Panel
5. Thank You and Error Message Panel
6. Hidden Panel

• System Generated Field Panel
• Author Entered Field Panel
• Form Title Panel
• End-user Entered Field Panel
• Thank You and Error Message Panel
• Hidden Panel

System Generated Panel 

Market Region

Market Region ASIA APAC EMEA LATAM

This is a Required field for GLU to process this request:

*Nation / Country Bangladesh Australia Hongkong United Kingdom Turkey Kuwait Bahrain Egypt Jordan Greece Oman Lebanon Romania Bulgaria France Poland Portugal Spain UAE Italy Russia Portugal Argentina Columbia Brazil

Form submission source

*PublishedDate

*Domain

Language Value

LanguageValue

Form Fields

 Author Input Panel

Author Input Panel - Required fields

Select the form Layout

*Type of Form Integration siteComponent slider contactCardForm

Analytics form type

*Type Of Form Contactform Inquiry Grievance

Analytics form title

*Request Type

Lead

Case

Xmlformname

Date field format

Select the date format used in the form (if date field is used) yyyy/mm/dd mm/dd/yyyy dd/mm/yyyy yyyy-mm-dd mm-dd-yyyy dd-mm-yyyy

Author Input Panel - Optional fields

Campaign Nam

Campaign Term / Key phrase

Campaign Content

Analytics Source

Analytics Medium

Email

WebSite

Quote Result / information

Form Title  Panel

User Input Panel

*Emirates

*Select Your Emirate Dubai Abu Dhabi Sharjah Ras Al Khaima Fujeirah Umm Al Quain Ajman

*Individual or Group policy?

*Individual or Group policy? Individual (Personal) Group of Employees

*I am interested in

*I am interested in *Financial support due to Loss of Life, Disability, Accident, Critical illness etc. *Creating wealth for future needs for Retirement, Child Education, Investments, Savings etc. *Obtaining basic Individual Medical Insurance *Existing Customer Inquiry

If salary below 4000 is selected or insured is on student visa or if documents for new born are not yet issued,  you will be routed to another portal to complete the formalities.

Place of Visa Issuance Sharjah Dubai Ajman RAK UAQ Fujairah UAE/GCC nationals

Who is the Insurance for?

Who is the Insurance for? Myself My Dependent My Domestic Helper An Employee Dependent & Me

*Visa Sponsor

*Visa Sponsor Partner/Investor Mother/Father Husband/Wife Company University Sibling(s)

Please select your visa type

Please select your visa type Resident visa or UAE/GCC national Student Visa Business Visa

Please select your age group of the insured

Please select your age group of the insured Between 4 month and 79 years and 6 months 4 months old or younger above 79 years and 6 months

Please select the salary of the insured

Above 4,000 AED

4,000 AED and below or Unemployed

Are the documents of the new born such as visa/passport/emirates ID issued?

Yes

No

*Salutation

*First Name

*Last Name

*Phone (971xxxxxxxxx)

*Email

*Date of Birth (dd/mm/yyyy)

Company Name

Number of employees (Minimum 4)

Industry

Industry Agriculture; plantations; other rural sectors Basic Metal Production Chemical industries Commerce Construction Education Financial services; professional services Food; drink; tobacco Forestry, wood, pulp and paper Health services Hotels; tourism; catering Mining (coal; other mining) Mechanical and electrical engineering Media; culture; graphical Oil and gas production; oil refining Postal and telecommunications services Public service Shipping; ports; fisheries; inland waterways Textiles; clothing; leather; footwear Transport (including civil aviation; railways; road transport) Transport equipment manufacturing Utilities (water, gas, electricity)

Please do not share credit card details or any financial information in this form

Message (Max. 1000 characters)

SUBMIT

Thank You/Error Panel Configuration

Message Option Same page-fadeout Same page-fixed New page

Settings for same page thank you/error message

Message Delay

Error

An error has occurred. Please try again later.

Thank you

Your request has been submitted successfully.

You can also contact MetLife at the numbers below.

• UAE: 800 6385433
• Qatar: 800 9711
• Bahrain: 800 08033
• Kuwait: +965 2 2089333
• Oman: 800 70708
• Any other country: +971 4 415 4555

Settings for separate page thank you/error message

Error Page

Thank You Page

Page Target

Page Target Same Tab New Tab

Hidden Panel

Name Of The Template