Travel Insurance Policy || United Ajod Insurance Company Ltd

Insurance Proposal Form

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Your Full Name

Your Full Address

District *

VDC/Municipality *

Tole *

Ward No. *

Phone Number *

Date of Birth(AD) *

Email address *

Father's Name *

Grand Father's Name *

PAN/VAT No. *

Citizenship No. *

Citizenship Issued Date *

Citizenship Issued Place *

PP Size Photo *

Citizenship Front *

Citizenship Back *

Passport Number *

Place of Visit *

Occupation *

Doctor's Name (Optional)

Doctor's Address (Optional)

Doctor's Contact No. (Optional)

Age *

Days *

$Rate

Plan *

Cover

Upload Images [Multiple Select]

(Passport, Citizenship Card, PP Size Photo etc.)

Policy Effective From[yyyy-mm-dd]:

Note: If your payment date is after above date, policy will be effective from payment date.