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Bajaj Allianz travel form is the best way to plan your trip and make sure that you are well insured for emergency medical expenses, loss of baggage, missed flights and more. The form not only makes the planning process easier but it is also a great way to get travel insurance at a discounted price. Make sure to take advantage of the various discounts available online before purchasing your policy. For more information on Bajaj Allianz travel form and how to purchase coverage, please visit our website. You can also call our toll-free number 1-877-777-8491 and speak to one of our customer service representatives. We would be happy to help you with your travel needs.

Below is the information in regards to the PDF you were in search of to complete. It can show you just how long it will need to complete bajaj allianz travel form, exactly what fields you will need to fill in and several additional specific details.

QuestionAnswer
Form NameBajaj Allianz Travel Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesimd, Ltd, bajaj allianz general insurance proposal form no No Download Needed needed, bajaj allianz travel elite proposal form

Form Preview Example

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Bajaj Allianz General Insurance Com pany Lim ited

Regd. Office & Head Office : GE Plaza, Airport Road, Yerawada, Pune - 411 006.

P-9910

Interm ediary Code

TRAVEL ELITE PROPOSAL FORM

1.Nam e of the Proposer :

2.Address :

3.Phone No. :

4.E-m ail

5.Date of Birth

6.

Passport No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assignee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Departure Date :

 

 

 

 

 

 

 

 

 

 

 

 

 

Arrival Date :

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Plan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Travel Elite -

 

 

 

Silver

 

 

Gold

 

 

 

Platinum

 

 

 

 

 

 

 

 

Elite Asia Flair

 

 

Elite Asia Suprem e

 

 

 

Travel Elite Fam ily

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Travel Age Elite -

 

 

 

Silver

 

 

Gold

 

 

 

Platinum

 

 

 

Student Elite -

 

 

 

Standard

 

 

Silver

 

 

 

Gold

 

 

DOWNLOADED FROM WWW.INSUREATCLICK.COM - IMD CODE : 10000006

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Corporate Elite

Corporate Lite

 

 

 

 

Corporte Plus

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Choose Geographic Coverage :

Excluding USA / Canada

 

 

Including USA / Canada

 

 

Asia Including Asia (Excluding Japan)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fam ily M em bers

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S.No.

 

 

Nam e

 

 

Date of Birth

Gender

 

 

Passport No.

Assignee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a) Are you suffering or have you

b) Have you been

c) Are you currently or

 

d) Have you ever

Please m ention the

 

 

 

 

ever suffered from any illness/

adm itted to any hospital

in past have been on

 

claim ed under your

nam e, address and

 

S.No.

 

disease / ailm ent upto the date of

/ nursing hom e / clinic

any m edications ?

 

earlier travel policy?

telephone no. of your

 

 

m aking this proposal or suffer

for treatm ent or

Please m ention

 

If yes, please give

fam ily doctor and/ or

 

 

 

 

 

 

 

 

 

from physical defect or deform ity?

observation ?

 

 

 

details under the

specialist

 

 

 

 

Please give details

 

Please give details

 

 

 

section claim ed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

±

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If answer to any of the above a) to d) is Yes.

Please give details :

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

I hereby declare & warrant that the above statem ent is true and com plete in all respects and that inform ation relevant to m y application of insurance has been disclosed to you. I understand that this policy does not cover any pre-existing m edical condition/ injury/ illness/ deform ity and com plications arising from them that are declared or undeclared. I will not be travelling against the advice of a physician will not be travelling for the purpose of obtaining m edical treatm ent. I consent to Bajaj Allianz seeking m edical inform ation from any doctor in respect of any m atter relating to m y physical or m ental health and I authorize and consent to him giving such inform ation to Bajaj Allianz and / or to the claim s adm inistrator or m edical advisors.

I agree to this proposal and the declaration shall be the basis of the contract between m e and Bajaj Allianz and I agree to accept the policy subject to the term s & conditions prescribed by Bajaj Allianz General Insurance Com pany Ltd.

Paym ent Details

Cash / Cheque

Am ount

Cheque No.

Cheque Dt.

Bank/ Nam e

Branch

Signature :

Date :

Additional inform ation to be com pleted by the student (Only for student com panion plan)

λ

Nam e of the Student

:

 

 

λ

Date of Birth

:

 

 

λ

Nam e of the School overseas

:

 

 

λ

Detailed address of the school/ Telephone no:

 

DOWNLOADED FROM WWW.INSUREATCLICK.COM - IMD CODE : 10000006

λ

Course opted for

:

λ

Duration of the course

:

λ

Num ber of Sem esters

:

λ

Tuition fees per Sem ester

:

λTuitions financed by (Self, parents, borrowing from bank or FI's), please give details

λHave you undergone m edical exam ination/ fitness test?

λWould like to state any thing that is not asked which you m ay want the insurer to know?

Nam e :

Signature :

 

Date :

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