Fast International Travel | Overseas Mediclaim & Travel Insurance

Overseas Mediclaim & Travel Insurance

Date of Departure :

Date of return :

Period of Insurance (Days) :

	A to C
	A to N

Person to be Insured (Mr./ Mrs./ Miss.):

Date Of Birth:

Age:

Premium US $:

Exchange Rate:

Premium NRs:

Stamp Duty:

Sub Total:

13% VAT:

Total:

Passport No.:

Place of Visit:

Occupation:

Purpose of Visit:

Address of Applicant:

Telephone No.:

Local		Country of Visit
Contact person in case of emergency (including their address and telephone number):
Full Name		Full Name
Address		Address
Phone No.		Phone No.
E-mail address		E-mail address

Details of ay condition for which you and/or any of your travelling dependants have previously taken medication, had treatment or sought medical advice for in the last two years.

Name, Address and Telephone Number of your and all travelling dependants regular Doctor. If you do no have a regular doctor please provide the contact details if the last doctor you saw.

Have you or any of your travelling depandants made a claim, been refused cover, or had an Insurer decline or impose special conditions in respect of Life, Accidents, Sickness, Hospital Expenses or Travel Insurance in the last five years?
YES	NO	If Yes, Please provide details:

Signed Date: