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Personal Accident Insurance
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Basic Information
Insurance Type
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Motor
Fire
Marine
Overseas Mediclaim Insurance (Health)
Personal Accident
People's Personal Accident
Plan Type
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Insurance Sub Type
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Insurance Category
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Vehicle Information
Vehicle Price *
Vehicle Type *
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Capacity *
Policy Start *
Policy End *
Facility Excluding
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Personal & Vehicle Information
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Insured Full Name: *
Insured Address: *
Mailing Address: *
Mobile Number: *
Vehicle Brand/Make: *
Registration Number: *
NID: *
Vehicle Document(s)
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Email ID: *
City: *
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Bagerhat
Bandarban
Barguna
Barisal
Bhola
Bogra
Brahmanbaria
Chandpur
Chattogram
Chuadanga
Cox's Bazar
Cumilla
Dhaka
Dinajpur
Faridpur
Feni
Gaibandha
Gazipur
Gopalganj
Habiganj
Jamalpur
Jessore
Jhalokati
Jhenaidah
Joypurhat
Khagrachhari
Khulna
Kishoreganj
Kurigram
Lakshmipur
Lalmonirhat
Madaripur
Magura
Manikganj
Meherpur
Moulvibazar
Munshiganj
Mymensingh
Naogaon
Narail
Narayanganj
Narsingdi
Natore
Nawabganj
Netrakona
Nilphamari
Noakhali
Pabna
Panchagarh
Patuakhali
Pirojpur
Rajbari
Rajshahi
Rangamati
Rangpur
Satkhira
Shariatpur
Sherpur
Sirajganj
Sunamganj
Sylhet
Tangail
Thakurgaon
Mailing City *
Select
Bagerhat
Bandarban
Barguna
Barisal
Bhola
Bogra
Brahmanbaria
Chandpur
Chattogram
Chuadanga
Cox's Bazar
Cumilla
Dhaka
Dinajpur
Faridpur
Feni
Gaibandha
Gazipur
Gopalganj
Habiganj
Jamalpur
Jessore
Jhalokati
Jhenaidah
Joypurhat
Khagrachhari
Khulna
Kishoreganj
Kurigram
Lakshmipur
Lalmonirhat
Madaripur
Magura
Manikganj
Meherpur
Moulvibazar
Munshiganj
Mymensingh
Naogaon
Narail
Narayanganj
Narsingdi
Natore
Nawabganj
Netrakona
Nilphamari
Noakhali
Pabna
Panchagarh
Patuakhali
Pirojpur
Rajbari
Rajshahi
Rangamati
Rangpur
Satkhira
Shariatpur
Sherpur
Sirajganj
Sunamganj
Sylhet
Tangail
Thakurgaon
Year of Manufacture *
select
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
Registration Date: *
Engine Number: *
Chassis No: *
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Travel Information
Stay Duration
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Date of Birth
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Personal Information
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Visa Type *
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Medical
Non-Medical
Policy Date *
Name *
Address *
City *
Bagerhat
Bandarban
Barguna
Barisal
Bhola
Bogra
Brahmanbaria
Chandpur
Chattogram
Chuadanga
Cox's Bazar
Cumilla
Dhaka
Dinajpur
Faridpur
Feni
Gaibandha
Gazipur
Gopalganj
Habiganj
Jamalpur
Jessore
Jhalokati
Jhenaidah
Joypurhat
Khagrachhari
Khulna
Kishoreganj
Kurigram
Lakshmipur
Lalmonirhat
Madaripur
Magura
Manikganj
Meherpur
Moulvibazar
Munshiganj
Mymensingh
Naogaon
Narail
Narayanganj
Narsingdi
Natore
Nawabganj
Netrakona
Nilphamari
Noakhali
Pabna
Panchagarh
Patuakhali
Pirojpur
Rajbari
Rajshahi
Rangamati
Rangpur
Satkhira
Shariatpur
Sherpur
Sirajganj
Sunamganj
Sylhet
Tangail
Thakurgaon
Email Address *
Mobile Number *
Passport No. *
Passport's Personal Data with Photo *
To upload multiple file select together
Destination Countries *
Auto Renew
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No
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Fire Insurance
Full Name of Proposer
Proposer Phone
Proposer Email Address
Proposer Address
Name of Partners Bank(If Any)
Partners Bank Address (If Any)
Trade of Profession
Terms on Insurance Form
Submit
Marine Information
Full Name of Proposer
Proposer Phone
Proposer Email Address
Proposer Address
Name of Insured M/S
Insured M/S Address
Nature of Commodities
Mode of Packing
Insurance Date
Via
To Be Shipped Per
Risk Covered
Amount Tk
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Insurance Information
Plan Type *
Select
Individual
Group Basis
Class of Occupation *
Select
Class-1--Accountants ,Administrative Or Clerical Duties ,Bankers ,Medical Practitioner ,Mercantile Asstt And Those Engaged Solely In Executive.
Class-2--Architects ,Master Tradesmen Who Supervise But Do Not Manual Work) ,Planters Electrical Engineer(Superintending Only).
Class-3--Motor Engineers ,Other Occupations Will Be Considered On Application. ,Persons Engaged In Manual Work No Involving Unusual Hazards Or Wood Working Machinery. ,Veterinary Surgeons.
Risk Cover *
Select
Table "A"--Death ,Permanent Disablement ,Temporary Disablement.
Table "B"--Death ,Partial Disablement ,Permanent Total Disablement.
Table "C"--Accidental Death Only.
Sum Insured *
0.00
Date of Birth *
Company Name *
Concern Person *
Mobile No *
Email *
Download File *
Download this file and upload after fill up the information
Upload File *
Upload
Submit
Benefits
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Personal Information
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Full Name of Insured *
Insured Email*
Insured Address *
Insured Occupation *
Mobile Number:
Passport / NID with Photo *
Period of Insurance *
Name of Beneficiary *
Relationship with Beneficiary *
Select
Brother
Chief Operating Officer
Father
Mother
Sister
Wife
Auto Renew
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no
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Insurance Information
Plan Type *
Select
Individual
Group Basis
Number of People *
Company Name *
Concern Person *
Mobile No *
Email *
Download File *
Download this file and upload after fill up the information
Upload File *
Upload
Submit
Sum Insured *
100,000.00
Date of Birth *
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Personal Information
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Full Name of Insured *
Father's Name *
Mother's Name *
Spouse's Name *
Insured Email*
Insured Address *
Insured Occupation *
Mobile Number *
Passport / NID with Photo *
Period of Insurance *
Name of Beneficiary *
Relationship with Beneficiary *
Select
Brother
Chief Operating Officer
Father
Mother
Sister
Wife
Auto Renew
Yes
No
Schedule Attachment for Group *
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Operational Manager Name *
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