Prime E-Insurance
Hot Line:
(+88)09644448888
Overseas Mediclaim Policy Form
Insurance Sub Type
Select Category
Business & Holiday
Employment
Study
OMP Type
Select Category
FOR SCHENGEN COUNTRIES ONLY
NON-SCHENGEN COUNTRIES + USA CANADA EXCLUDING SCHE
NON-SCHENGEN COUNTRIES
SCHENGEN COUNTRIES + USA CANADA + WORLDWIDE
Travel Days
Please enter Travel Days between 180 and 365.
Please enter Travel Days between 1 and 180.
Please enter Travel Days between 180 and 365.
Date Of Birth
Premium
VAT
Total
First Name
Last Name
Father Name
Insured Address
Gender
Select Gender
Male
Female
Mobile Number
Insured Email
Occupation
Period From
Period to
Purpose of Trip
Select Gender
State official
Holiday travel unconducted tour
Holiday travel individual
Passport Number
Physician Name Mobile Number
Destination
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands (the)
Tuvalu
Uganda
Ukraine
United Arab Emirates (the)
United Kingdom of Great Britain and Northern Ireland (the)
United States Minor Outlying Islands (the)
United States of America (the)
Uruguay
Uzbekistan
Vanuatu
Venezuela (Bolivarian Republic of)
Viet Nam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas (the)
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory (the)
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands (the)
Central African Republic (the)
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands (the)
Colombia
Comoros (the)
Congo (the Democratic Republic of the)
Congo (the)
Cook Islands (the)
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic (the)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands (the) [Malvinas]
Faroe Islands (the)
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories (the)
Gabon
Gambia (the)
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (the)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (the Democratic People's Republic of)
Korea (the Republic of)
Kuwait
Kyrgyzstan
Lao People's Democratic Republic (the)
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands (the)
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (the Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands (the)
New Caledonia
New Zealand
Nicaragua
Niger (the)
Nigeria
Niue
Norfolk Island
Northern Mariana Islands (the)
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines (the)
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Republic of North Macedonia
Romania
Russian Federation (the)
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan (the)
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan (Province of China)
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
MEDICAL HISTORY TO BE COMPLETED BY THE PROPOSER/SPOUSE
Please Answer the Following questions in Yes or No ( A desh is not sufficient and give full details)
1.
Are you in good health and free form physical and mental diseaseor infirmity?
Yes
No
2.
Have you ever sufferd form
(a)
Any nervous, mental or psychiatric disease, slipped disc or other spinal disorder, fainting episode, blackout, fit or paralysis of any kind?
Yes
No
(b)
High blood pressure, heart diseases including ischaemic heart disease, piles, varicose veins, other circulatory disorders or rheumatic fever?
Yes
No
(c)
Hernia, any rheumatic or joint disease Urinary disease or diabetes?
Yes
No
(d)
Any respiratory or allergic disease, or any disorder of the stomach, bowel or gallbladder?
Yes
No
(e)
Any other complaint requiring specialist's consultation or surgical or hospital treatment or investigations?
Yes
No
(f)
Any complaint or tendency that may necessitate such consultation or treatment in the future?
Yes
No
(g)
A "slipped dise" or other spinal disorder, a hernia, or any rheumatic or arthritic condition?
Yes
No
(h)
Any respiratory, urinary or allergic condition or any disorder of the stomach or bowels?
Yes
No
(i)
Any symptom or tendency that might necessitate such consultation or treatment in the future?
Yes
No
3.
Are there any additional facts affecting the proposed insurance which should be disclosed to Insurers?
Yes
No
4.
Have you any intention of engaging in winter sports or pastimes rendering you liable to personal injury?
Yes
No
5.
Give particulars of any other illness or disease or accident sustained by you during the 12 months preceding the first day of Insurance in the table below.
Yes
No
6.
Do You Ordinarily enjoy good health
Yes
No
Submit
×
Calculation Result
Premium:
VAT:
Total:
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OVERSEAS MEDICLAIM POLICY FOR BUSINESS & HOLIDAYS (B & H) TOUR
OVERSEAS MEDICLAIM POLICY FOR EMPLOYMENT & STUDIES (SCHENGEN AND/OR NON- SECHENGEN COUNTRIES-UNDER PLAN “C” AND PLAN “D”)
Contact us
Address: Unique Heights (9th Floor) 117, Kazi Nazrul Islam Avenue, Dhaka-1000, Bangladesh.
Call : (+88)09644448888, (+88)0255138657-62
Email : info@prime-insurance.net
BIN No:- 000162206-0208
