Scribd Logo
Upload

Welcome to Scribd!

  • Insurance Course

    Uploaded by

    Zobaer Hossan
    10 views5 pages
    This document contains a proposal form for a travel medical insurance policy from Multifarious Insurance Company. The form requests information from applicants such as name, address, mobile number, email, occupation, date of birth, age, passport number, purpose of trip, departure and return dates. It also asks for medical history and physician details. The second part of the document outlines the offerings of the Overseas Mediclaim Policy, including medical expenses and hospitalization coverage up to $50,000, transport costs in case of illness or accident, $500 for emergency dental care, $100 per day up to $1000 for travel of an immediate family member, emergency return home costs, and compensation for lost documents or delays.

    Original Description:

    Insurance proposal formate

    Original Title

    Insurance course

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document contains a proposal form for a travel medical insurance policy from Multifarious Insurance Company. The form requests information from applicants such as name, address, mobile number, email, occupation, date of birth, age, passport number, purpose of trip, departure and return dates. It also asks for medical history and physician details. The second part of the document outlines the offerings of the Overseas Mediclaim Policy, including medical expenses and hospitalization coverage up to $50,000, transport costs in case of illness or accident, $500 for emergency dental care, $100 per day up to $1000 for travel of an immediate family member, emergency return home costs, and compensation for lost documents or delays.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    10 views5 pages

    Insurance Course

    Uploaded by

    Zobaer Hossan
    This document contains a proposal form for a travel medical insurance policy from Multifarious Insurance Company. The form requests information from applicants such as name, address, mobile number, email, occupation, date of birth, age, passport number, purpose of trip, departure and return dates. It also asks for medical history and physician details. The second part of the document outlines the offerings of the Overseas Mediclaim Policy, including medical expenses and hospitalization coverage up to $50,000, transport costs in case of illness or accident, $500 for emergency dental care, $100 per day up to $1000 for travel of an immediate family member, emergency return home costs, and compensation for lost documents or delays.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 5

    Multifarious Insurance Company Limited

    Multifarious Tower (5th floor), Kandir Par, Cumilla, Bangladesh.


    E-mail: multifarious@gamil.com

    PROPOSAL FORM
    (FOR TRAVEL MEDICLAIM INSURANCE)
    1. Name of Proposer:

    2. Address

    3. Mobile No.

    4. Email

    5. Proposers Actual Occupation

    6. Date of Birth

    7. Age

    8. Passport Number

    9. Purpose of Trip
    10.Proposed date of departure from the People’s Republic of Bangladesh

    11.Proposed date of departure from the People’s Republic of Bangladesh

    12.Geographical Limit

    13.Name and Address of the usual Physician

    14.MEDICAL HISTORY TO BE COMPLETED BY THE PROPOSER

    Signature………………………….

    Place……………………………….

    Date………………………………...
    OVERSEAS MEDICLAIM POLICY
    (TRAVEL INSURACE)

    OFFRINGS
    NO. COVERS LIMITS
    01 Medical Expenses and Hospitalization abroad US $50,000

    02 Transport in case Illness or Accident Actual Expenses

    03 Emergency Dental Care US $500

    04 Travel of one immediate member Us $100 per day, Maximum $ 1000

    05 Emergency Return Home Actual Expenses

    06 Loss of Passport, Driving Licenses, NID Card US $ 250

    07 Compensation for delay in the Arrival of US $ 250


    Language
    08 Delayed Departure US $ 250
    TERMS AND Conditions
    1. Policy holders can not travel against the advice of a physician.
    2. Policy holder is not on waiting list for any medical treatment.
    3. Policy holder will not travel for the purpose of obtaining medical tratment6
    4. Policy holder have not received a terminal prognosis for a medical condition before this day.

    You might also like