Bajaj Allianz Travel Elite Proposal Form
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2Bajaj Allianz General Insurance Company Limited
Regd. Office & Head Office : GE Plaza, Airport Road, Yerawada, Pune - 411 006.
Intermediary Code
TRAVEL ELITE PROPOSAL FORM
1.
Name of the Proposer :
2.
Address :
3.
Phone No. :
4.
E-mail
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 Supreme
Travel Elite Family
Travel Age Elite -
Silver
Gold
Platinum
Student Elite -
Standard
Silver
Gold
Corporate Elite
Corporate Lite
Corporte Plus
Choose Geographic Coverage : Excluding USA / Canada
Including USA / Cana
Asia Including Asia (Excluding Japan
Family Members
S.No.
Name
Date of Birth
Gender
Passport No.
Assignee
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a) Are you suffering or have you
b) Have you been
c) Are you currently or
d) Have you ever
Please mention the
ever suffered from any illness/
admitted to any hospital
in past have been on
claimed under your
name, address and
disease / ailment upto the date of
/ nursing home / clinic
any medications ?
earlier travel policy?
telephone no. of your
S.No.
making this proposal or suffer
for treatment or
Please mention
If yes, please give
family doctor and/or
from physical defect or deformity?
observation ?
details under the
specialist
Please give details
Please give details
section claimed.
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