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.
| Question | Answer |
|---|---|
| Form Name | Bajaj Allianz Travel Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | imd, Ltd, bajaj allianz general insurance proposal form no No Download Needed needed, bajaj allianz travel elite proposal form |
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Bajaj Allianz General Insurance Com pany Lim ited
Regd. Office & Head Office : GE Plaza, Airport Road, Yerawada, Pune - 411 006.
Interm ediary Code
TRAVEL ELITE PROPOSAL FORM
1.Nam e of the Proposer :
2.Address :
3.Phone No. :
4.
5.Date of Birth
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Passport No. |
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Assignee |
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7. |
Departure Date : |
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Arrival Date : |
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8. |
Plan |
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Travel Elite - |
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Silver |
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Gold |
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Platinum |
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Elite Asia Flair |
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Elite Asia Suprem e |
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Travel Elite Fam ily |
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Travel Age Elite - |
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Silver |
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Gold |
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Platinum |
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Student Elite - |
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Standard |
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Silver |
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Gold |
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DOWNLOADED FROM WWW.INSUREATCLICK.COM - IMD CODE : 10000006
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Corporate Elite |
Corporate Lite |
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Corporte Plus |
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Choose Geographic Coverage : |
Excluding USA / Canada |
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Including USA / Canada |
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Asia Including Asia (Excluding Japan) |
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Fam ily M em bers |
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S.No. |
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Nam e |
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Date of Birth |
Gender |
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Passport No. |
Assignee |
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a) Are you suffering or have you |
b) Have you been |
c) Are you currently or |
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d) Have you ever |
Please m ention the |
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ever suffered from any illness/ |
adm itted to any hospital |
in past have been on |
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claim ed under your |
nam e, address and |
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S.No. |
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disease / ailm ent upto the date of |
/ nursing hom e / clinic |
any m edications ? |
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earlier travel policy? |
telephone no. of your |
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m aking this proposal or suffer |
for treatm ent or |
Please m ention |
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If yes, please give |
fam ily doctor and/ or |
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from physical defect or deform ity? |
observation ? |
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details under the |
specialist |
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Please give details |
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Please give details |
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section claim ed. |
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If answer to any of the above a) to d) is Yes.
Please give details :
~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
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~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~
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
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 |
: |
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λ |
Date of Birth |
: |
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λ |
Nam e of the School overseas |
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λ |
Detailed address of the school/ Telephone no: |
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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 : |
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Date : |
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