PROPOSAL FORM FOR MEDICLAIM INSURANCE
 
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Date of Departure
Date of Return  
Period of Insurance
(Total number of days outside of the Kingdom of Nepal)
   
Geographical area 1 or 2
Selected plan A or B
   
Persons to be Insured
(state Mr./Mrs./Miss)
 Date of Birth Passport No.
1.
2.
3.
4.
5.
     
Original address of Applicant  
Telephone Number  
   
 

Current Address:
   
Contact Phone  
Email Address  
Address  
 
I hereby declare that all persons named in this application form are in good health and will not travel unless they are in good health and fit to undertake the insured trip nor has anyonenamed in this application been diagnosed with and does not suffer fron any medical condition for which medical treatment may be required.Futhermore all persons named in this application will not travel against medical advice or for the purpose of obtatining medical treatment. I further declare that i am not aware of any reason, in connection with the health of anyone named on this application, that could result in any claim under this insurance. I am aware that this is not a general health insurance policy and that pre-exixting medical conditions are not covered. I have been made aware of the important terms and conditions of this insurance and that certain restrictions to cover do apply. I also understand that this application does not feature all of the coverage issued, terms, conditions and exclusions which are fully described in the certificate wording.
I am a permanent resident of Kingdom of Nepal and I am over 18 years of age.
Date
 
 
 
 
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