Special Travel Declaration

1. Please provide your travel patterns over the past 90 days or from 1st Jan 2020 -

Name of the
Cities Date of Purpose of
Country’s Date of Arrival
Traveled to Departure Travel
Traveled to

2. Please provide details of your intended future travel plans for the next 90 days -

Intended date of
Name of the
Cities to be travel ( Date & Intended Purpose of
Country’s to be
traveled month to be duration travel
Traveled to
mentioned )

Declaration
I confirm that the answers I have given are, to the best of my knowledge, true,
and that I have not withheld any material information that may influence the
assessment or acceptance of this application.

I agree that this form will constitute part of my application for insurance(s) and
that failure to disclose any material fact known to me may invalidate my
insurance(s).

Signed at on this day of ,

Applicant Signature