The Oriental Insurance Company Ltd

Division IX, Homi Modi Street, Fort, Mumbai 400023

PROPOSAL FORM
Overseas Student Travel Insurance
1. Personal Details
Proposers Name

: Mr. /Ms.: ____________ ____ ____________ __________________________

____________ ____ ____________ __________________________

(as per passport)

Correspondence
Address

: House No. & Street __________ ____ __________ __________________________

____ ____________ ____________ ______ __________________________
Locality ___________________
: State_______________

City ______________________
Pin

____________

Phone No. (India)

: _________________

Mobile No.: ___________________

Mail ID

: __________________

Fax No. ________________

Date of Birth

: _________________

Passport No. : _________________

Place of Study abroad

_________________ __________________________
(Name and address of the Institution) ____________ __________________________
____________ __________________________

Mothers Full Maiden Name: Ms: ____________ __________________________

.
Sponsors Name
: Mr. /Ms ______________ __________________________
Sponsors Date of Birth: ____ __
Sponsors Passport No. ______________
Sponsors Relationship ( _________________If not applicable then PAN No.)
With the student
Sponsors address

: House No. & Street __________ __________________________

____________ ______ __________________________
Locality ___________________

City ________________

State

Pin _________________

___________________

Phone No.: _________________

Mobile No. _____________________

Parent /Guardian of
Mr. /Ms.: ____________ __________________________
The insured & address
(also the authorised NOMINEE to House No. & Street __________ __________________________
received all claim proceeds)
____________ ______ __________________________

Locality ___________________

City ________________

State

Pin _________________

___________________

Phone No.: _________________

Mobile No. ____________________

E-Mail ID : __________________

Fax No. ________________

Parent /Guardians
Passport No/PAN NO.. : _________________

2. Geographical Scope :
3. Plan Requested
4. Departure Date

Relationship
with student _________________

Worldwide excluding US/Canada Worldwide

PLAN 1 PLAN 2 PLAN 3 PLAN 4 PLAN 5

: _________________

5. Arrival Date

: _________________

6. Months required for ____Numbers of Months

(Each 30 day duration inclusive departure and arrival date will constitute a month. Part month will quality as the next higher
Month.)

__________________________________________________________________________________________________________
I / We agree that the policy shall become voidable at the option of the company in the event of any untrue or incorrect
statement,
mispresentation, non-descriptions or non-disclosure in any material particular in the proposal form/personal statement,
declaration
and connected documents or any material information has been withheld by me/us or anyone acting on my / our behalf to obtain
any benefit under this policy.
I/We the undersigned hereby declare and warrant that the above statements are true, accurate and complete. I / We desire to
effect
And insurance as described herein with company and I/We agree that this proposal and declarations hereto shall be the basis of
Contract between me/us and the company and I/We agree to accept a policy subject to the conditions prescribed by the
company.
Date: -

___________________________
Signature of Parent / Guardian

Date: -

___________________________
Signature of the Insured Person or
His / her Authorised representative

Documents required along with this proposal form:

1. University admission letter & Name & Address.
2. Passport copy of Sponsored.
3. Passport copy of Insurer.
4. Letter from the sponsored