Your MetLife UAE Medical Discount Card

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

Preferred contact method

Email

Telephone

Salutation

First Name

Last Name

Phone (971xxxxxxxxx)

Email

Best time to Contact

Best time to Contact 8:30 AM to 10:00 AM 10:00 AM to 11:30 AM 11:30 AM to 1:00 PM 1:00 PM to 2:30 PM 2:30 PM to 4:00 PM 4:00 PM to 5:00 PM

Individual or Group policy?

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

I am interested in

I am interested in Individual Medical Insurance

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)

*By checking this box, you agree for a MetLife advisor to contact you by phone or email to discuss your life insurance needs.

SUBMIT

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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