Pruguti Insurance Limited
Ilead Office
Ptugarilnsuronce Bhaban,
E, ail :u
)A)l
Kdetoi BazaL Dhdkd-1215
f!1: PABX:91i358A 2, Fat:gaA 2 B122tBt)
aA:Iydgatiinsurance..a"L:in:foaA.pneatiirsuMhce.cah
lyeb: ltv.proqdtii$trance.ca
PROPOSAL FORM FOR OYERSEAS NIEDICLAIM POLICY (BUSINESS AND TIOLIDAYS)
(To be submitted in orisinalwith nro copies)
(A\ailablelo persons in lhe
age group 6 monthsro 79 _veaB)
IIII]
OVI'RSEAS TIIDICLAIM POLIC\ ?ROVIDES IIDEIINITI FOR f,XPENSf,S INCfIRRf,D FOR TfEDICAL
TREATUET_TTOTHI INSLiTD PERSON \IHO TRAyXIS ABROAD AS CORPOR{TE CLIINT. FOlt ILLN0SS, DlStrASliS
CO|_TR{CIf,D OR INJLXY SUSTAINED DURING OVERSEASTR{VEL A\D \lHiCE lS ?RIMARILY lN lH}: NAllll0 Oa
AN ETIf,RGENCY AN'D WIIICH IS Nf,CESSARY TO BI TINDXRTAKf,\ INITfEDIATELY, WITHOIJT \IIIICfl TIIE
PROPOSIRIS
PROPOSf,R IS
\OTABLETOLEAVf, THE OVIRSXAS COUNTNY lNDf,R VIDICAI- ADVICI,'I'IIII T'I'ENIIO\ OI fIII'
DIIAIV\ TO ]Tf,\I I] (\'f,DICAL HISTORY) OF THf, PRO?OSAL FORi\I, ESPECIALL}' IN RI'LA'IION 1'O
THX ?ROPOSAL FORIVT SHOIiLD BE COMPLXTED TO THf, BEST OT YOTIR XNO\YLEDCf, AND BXLIXF AND ALL
NII|I'If,RIAL TACIS T SHOULD BX DISCLOSID. IAILTIRE TO DO SO IIAY N'I]LLIFY COVI]R LNDf,R \N! POLICY
tssLxD,
+
A material lacl is one that is likcl) to influeDcc thc lnsu.cr's
should consult ComoratioD/ ComDany
iflou
ar€ in
dy
acceptance or assessmenl ollhe proposal. You
doubt as !o what consiitutes a material fact.
Name and siatus ofthe proposer (in block
Iel[r, as stated in the pasport
State $,herher Mr./ Mrc.l Miss/ Masrer
2.
L
4.
5.
Residence Ielephone No & Mobile No..
6.
7.
8.
9.
Olfice ltlephonc No.
Proposer's Actual Occupation Gpecil,!)
oluce Nene
and Address
ifan)
Asc (in completedyears)
Pdsport Nunrber (copy auached)
PlaD l')pe
Sclcnsen countries
\vorlchlide (excludino IISA & Canada)
pran
a l-'__-l
Non-Schensen countries
worldlvide (excludins USA & Canada)
Plan A
world\\ ide (including USA & Canad.)
worldrvide (i ncluding USA & Cmada)
Pran
Plan B
10.
.
s f-__l
Pumose ofTrip (State ofllcial/
holidly lrarel in conducred !our/
holidal travel individual)
Puposed date of depaturc from thc
Peoplc's Republic of Bangladesh (kindly
nole thar no extension
12
13.
ce
be granted)
Numbcr of d.vs slay oulside dre People's
Rcpublic of Bangladesh (kindl) notc
thal no cxtcnsion can be granted)
Ilinerary (State counLdes lnd placcs
vkiied and apprcxjmale number
10 bc
1,1. Name
and Address oflhe usual
and Registratlon No.
phlsician
Telephone No. Consulti!g Room/ Office/
I],.
IIIEDICALHIS'IORY
TO BE COMPLETED BY THtr PIIOPOSER /SIOT]SE
PLE1SE ANSWER TIIE FOLLOWING OUtrSIIONS T].{ YES OR NO (A DASH IS NOI SUFFICIE\T
:\ND (JvE FUI,L DETAILS.
1.
Are you in good health and free
trom physical and mentaldhease or inUrmity?
Have you ever suftered iionr
G)
Any nerlous. mental or psychiaLrio
disease, slipped disc
orolher splnal
disordcr, thintinB ephode. blackout,
fir or paralysis ofany ktudl
(b)
Hi8h blood prcssure, hear! diseases
including ischaemic head disease,
piles, raricose,cins. othercirculatory
disorders or rheumalic Ierer'l
G)
Hernia, any rheunlatic oljoint diseasc
Urinlr) dhease or diabetes?
(d)
An) respiratory or allergic
any disorder
olthc
disease, or
stomach. borvelor
gallblddner?
G)
Any olher compldint requiring
specialistrsconsultltionorsurgical or
hospital treatmen! or inlesligalions?
(1)
Any complaint orlendency that may
necessiiate such consultation or
trcamenl in thc future?
3.
Are thete any ldditionaltacts afiectinglhe
proposcd insurance \ihich should be
disclosed to Insure6?
.1.
Ha\e you
dy
inlenlion ofengaging in
\!in1er sports or pastimes rendering you
liable to personal iniury?
Circ particulars olany oiho illnes o.
djsease orrccident sustained b) you durinS
thc 12 months preccdinsrhe firsl day of
Insurancc in the lahle helow
Nature of illnesY dis€ase
Injury and treatnent received
1.
2.
Name of attendidg medical
practitior€r/ su rgeon with his
address and teleDhon. Nunber
give delails olan) knowledge ofany posirire exisrence or presence olany aihnent, siokness ur
injury which ma) requlre mcdical attcntion whils!on tour abroad.
Please
l.
2.
3.
I HEREBY DECLARE THAT
.
2.
.l .
4.
I
I
will
not be
tE
elling ag.in( thc adricc oI
a
phlsician.
larn nol or waltlng list for an) medicaltreatmcnt.
I rvill not bc lravclling for thc purpose of oblaining medical trealnlenl.
I have not received
a
terminal prognosis for
a
medical condilior belore lhis dat.
I lurrher declare and warant that the ebove stdicmcnts dre ltue and complelc. I conscnt to thc insurcN sceking
medical inlormation liom an) docror who has at an) lime a(ended concernirg an)lhing $hich affecls ny
ph)sical or menlai heallh, and I aulhorise the giving ol such inlormation as Van Ameyde UK Ltd. r' Specilty
Assist Ltd. od / or lhcir Progru Medioal Ad\isor rnay r€quire. I agree rhar dlis proposal shall fom lhe basis oI
lhe contlacl should lhe insurance be effected.
I
am willing to accept the Policy, subject to the terms, excepiiois and conditions prescribed by Corporador
D!tc
slsnatu
MM
DD
List of Schengen Countries
Austria, Relgium, Denmark Finland, France, Germany, Iccland, Italy, Greece, Luxembourg,
Netherlands, NoNay, Portugal, Spain, Sweden, Estoni., Latvia, Lithuania, Poland, Czech
Republic, Slovakia, Hungary, Slovcnir, Malta, Cyprus, Switzerland and Liechtenstein
OYERSEAS ]!IEDICLAI]\I POLICY
(TRAVEL INSURANCE)
PRODUCT BENEFTTS & LIMITATTONS
01.
Nledicdl Expenses & I lospltaliation alNad
02.
NledicalUxpenses
& lldpitalnadon nimad
03. NledicalExpenses & Ilospitalizltion abrcad tor Schengen Countrics
0rl. Transpoit or Rcpalrlation in c6e ofilLnes ofAccident
05. lmcrsency Dental Care
06. Reparinlion olFanily Nledical Travelling rvilh &c insu.cd
07. Repltrialio. of nrorlal rcmalns
08. Tnleloloae nnmediate fanrily memtd'
0t.
US$ 50.000 Excss USD 100 (worldwide
excluding USA/CANADA
US$ 100,000 Exc€sUSD 100 (world$ide
Fur.30
tis$
0n0
500,
lilh Nilnefrxli6le
Lxcss USS 50
USS 100perday. Mrximum LrS$ 1.000
Emergcncyrctunr honre folloelne deaih ofa close lamil, memb*
IE : l llE COMPANY WILL NOT BE LIABILE TO PROVIDE ANY ,\SSISTANCE WHICH ARLSI,S Dll{EC Il-Y OR
INDIRI]CTLY ]TROM A}.]Y ?RE.EIISTING N'iI]DICAI, CONDITION, SU]CIDE OR A'I'I'EM]'ED SUICIDE, MENTAL
II I NFSS PRF:TJNAN''Y OR (lIII.DRIRTII
NO