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Head Office: Babarmahal, G.P.O. Box 148, Kathmandu, Nepal.
Tel: 4231788, Fax: 4241517, E-mail: [email protected]
Branches: Birgunj - Biratnagar - Pokhara - Durbarmarg - Butwal - Lalitpur
525366 528524
4231581 550543 5001810
Person to be Insured (Mr. / Mrs. / Miss.) Contact person in case of an emergency (including their address and telephone number): Details of any condition for which you and/or any of your travelling dependants have previously taken medication, had treatment or sought medical advice for in the last two years: Name, Address and Telephone Number of your and all travelling dependants regular Doctor. If you do not have a regular doctor please provide the contact details of the last doctor you saw: Hav e you or any of your travelling dependants made a claim, been refused cover, or had an Insurer decline or impose special conditions in respect of Life, Accidents, Sickness, Hospital Expenses or Travel Insurance in the last five years?

MEDICAL HISTORY: Benefits may not be payable if you do not fully disclose any material facts which could influence our
assessment and acceptance of this application and, if you are in any doubt as to whether any facts are material, you should
disclose them. This applies even if medical advice has not been sought.
Liability of Himalayan General Insurance does not commence until the proposal is accepted, premium received and policy issued.
Please ensure you read the policy carefully for a detailed description of cover, limits and terms and conditions.
To be read and signed by the applicant
I hereby declare that all persons named in this application form are in good health and will not travel unless they are in good
health and fit to undertake the insured trip nor has anyone named in this application been diagnosed with and does not suffer from
any medical condition for which medical treatment may be required. Furthermore all persons named in this application will not
travel against medical advice or for the purpose of obtaining medical treatment. I further declare that I am not aware of any
reasons, in connection with the health of anyone named in this application that could result in any claim under this insurance.
I am aware that this is not a general health insurance policy and that pre- existing medical conditions are not covered. I have been
made aware of the important terms and conditions of this insurance and that certain restrictions to cover do apply. I also
understand that this application does not feature all of the coverage issues, terms, conditions and exclusions which are fully
described in the certificate wording.
I am a permanent resident of Nepal and I am over 18 years of age.

Source: http://hgi.com.np/wp-content/uploads/2013/03/Travel-Insurance-Proposl-form.pdf


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