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(011) 2571-3136

(011) 2573-3136

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Suggest a Travel Insurance Plan

Please fill-in the following details and we will get back to you with in 24 Hours with our recommendations.

Your Name*
Your E-Mail*
Contact Phone*
How do you want us to Contact You?*		Via E-mail Via Phone
Best Time to Call		In case we need some additional information
Are you looking for a Plan that provides		Better Benefits Low Premium
Does the Visitor have any Pre-existing Medical Condition		Yes No
Purpose of Your Visit*
Profile (Policy Type)*		Individual Student Family Frequent Flier/Multi Trip
Date of Birth (dd/mm/yyyy) *		(of eldest traveller in case of family plan)
Spouse to be Covered		Yes No
Date of Birth of Spouse (dd/mm/yyyy) *
Children (0-18)		0 1 2 3 4   Children (19-21) 0 1 2 3 4
Additional Adults Travelling with you		0 1 2 3 4 Other than yourself and spouse
Max Days per Trip		30 45 60 90
Travel Start Date (dd/mm/yyyy)*
Travel Duration (in Days)
Travel End Date (dd/mm/yyyy)*
Coverage Area*		Worldwide (Including USA/Canada) Worldwide (Excluding USA/Canada) Asia (Excluding Japan and others)
Coverage Amount		All Coverage Amounts US$ 10,000 US$ 15,000 US$ 25,000 US$ 30,000 US$ 50,000 US$ 100,000 US$ 150,000 US$ 200,000 US$ 250,000 US$ 500,000 Minimum Maximum Exact Range
Insurance Companies preference, if any		ICICI Lombard Bajaj Allianz TATA AIG Reliance General Cholamandlam MS IFFCO-TOKIO Royal Sundaram New India Assurance National Insurance United India Oriental Insurance Star Health
Notes/Comments, if Any

^*Person to be insured must be in India or Foreign National Staying in India for more than six months to Buy Travel Insurance policy.

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