Application Form - Gosecure -Travel Insurance (2)

Application Form – Go secure Travel Insurance Plan ________________________________ Premium Payable: Rs.______________________ Plan Type

Individual

Family

Period of Insurance (Departure Date): From_______________ To: ______________________

Particulars of Insured Name: _______________________________________________________________________ Date of Birth: _____________________________________________________(DD/MM/YY) Passport Number: ______________________________________________________________ CNIC: _______________________________________________________________________ Cell No: ______________________________________________________________________ Name of Beneficiary____________________________________________________________ Relationship with the Insured: ____________________________________________________ Beneficiary Address: ___________________________________________________________ Purpose of Visit: _______________________________________________________________ Destination: ___________________________________________________________________ Address: _____________________________________________________________________ _____________________________________________________________________________

Family detail (In case of Accompanying with Insured) Spouse Name: _________________________________ D.O.B: ________________________ Passport No___________________________________ CNIC #_________________________

Children’ Name

______________________________ Insured’s Signature

Date of birth

Passport No.

______________________________ Authorized Signature on behalf of Adamjee Insurance Company Limited.

Gender