DOWNLOAD PROPOSAL FORM

Proposal Form

Please fill in all the fields and submit it or fax at: +92-21-9204849

1. You are applying as
   
   Individual

   Group (If applying in group please give separate details for each traveler as per Group Form in addition to this form)

   Name of Applicant (as on passport)

   Citizenship

   Passport Number (please use additional sheet if more than one travelers are applying)

   Organization

   Date/Place of Entry in Pakistan

   Flight Number Time of Arrival

   Date/Place of Exit from Pakistan

   Flight Number Time of Departure

   Stay Duration in days

   Number of travelers to be insured

   Coverage Plan chosen (please tick) Classic Superior

   Purpose of visit (please tick)

Govt. Delegates Official Trade Delegates

Business Travelers Tourists

14. Contact information 1

Email.   :
Mobile  :
Phone   :
Fax      : 

15. Nominee Name: (please use the additional Boxes if there is more than one representative)

16. Nominee Address & Phone & Email

I declare that this information is true to the best or my knowledge

Name:

 

Group Form

Please fill in all fields if applicable.

1. Name of Applicant (as on passport)
2. Passport Number
3. Nominee Name (please use the additional sheet if there is more than one representative)
4. Nominee Address & Phone & Email

 

Claim intimation and Contacts

In case of claim please notify at the earliest by emailing us at : customerrelations@nicl.com.pk
or at fax #: +92-21-9204849

POLICY NUMBER:
CLAIMANT NAME/PASSPORT NO.
NATURE OF INJURIES
ACCIDENT DATE
CONTACT DETAILS