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Flight
Hotel
Tour
Visa
Helicopter
Insurance
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Flight Request
Flying From
*
Flying To
*
Date / Time
*
Date / Time (copy)
Number of Person
Adult
Selected Value:
1
Child
Selected Value:
0
Infant
Selected Value:
0
Group Name
Contact Person Name
*
Phone/Mobile No
*
Contact Email
Special Notes
Submit
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Hotel Request
CheckIn Date
*
CheckOut Date
*
Preffered Hotel Name
*
Hotel Location
*
City
*
Country
*
Number of Person :
Adult
Selected Value:
1
Child
Selected Value:
0
Infant
Selected Value:
0
Number of Room :
Single
Selected Value:
0
Double
Selected Value:
0
Triple
Selected Value:
0
Deluxe
Selected Value:
0
Suit
Selected Value:
0
Other Specify
Selected Value:
0
Group Name
Contact Person Name
*
Phone/Mobile No
*
Contact Email
Special Notes
Submit
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Tour Request
City/Cities
*
Travel Date
*
Number Of Days
*
Hotel Type
*
InterCity Transfer Preference
Number of Person :
Adult
Selected Value:
1
Child
Selected Value:
0
Infant
Selected Value:
0
Group Name
Contact Person Name
*
Phone/Mobile No
*
Contact Email
Special Notes
Submit
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Visa Request
Desire Country
*
Number of Person :
Adult
Selected Value:
1
Child
Selected Value:
0
Infant
Selected Value:
0
Group Name
Contact Person Name
*
Phone/Mobile No
*
Contact Email
Special Notes
Submit
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Request for Helicopter
Flying From
*
Flying To
*
Journey Date
*
Number of Person :
Adult
Selected Value:
1
Child
Selected Value:
0
Infant
Selected Value:
0
Group Name
Contact Person Name
*
Phone/Mobile No
*
Contact Email
Special Notes
Submit
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Individual Insurance Form
Name
*
-- Select Title --
Mr.
Mrs.
Miss.
Master.
Name
*
Date Of Birth
*
Phone/Mobile No
*
Email
Address
*
Address Line 1
City
State / Province / Region
Passport Number
*
Purpose Of Trip
*
-- Select Title --
State official
Holiday travel in conducted tour
Holiday travel individual
Proposed date of departure from Bangladesh
*
Number of days stay outside Bangladesh
*
Geographical Limit
*
Accompanying person(s)
*
(If yes please complete separate form for each person)
Medical History to Be Completed by The Proposer(Please Answer the Following Questions In Yes or No)
Are you in good health and free from physical and mental disease or infirmity?
*
First Choice
Second Choice
Have you ever suffered from:
Number of Person :
a) Any neruous, mental or psychiatric disease, slipped disc or other spinaldisorder, fainting episode, blackout, fit or paralysis of any kind?
*
First Choice
Second Choice
b) High blood pressure, heart diseases including ischemic heart diseasepiles, varicose veins, other circulatory disorders or rheumatic fever?
*
First Choice
Second Choice
c) Hernia, any rheumatic or joint disease, urinary disease or diabetes?
*
First Choice
Second Choice
d) Any respiratory or allergic disease, or any disorder of the stomach,bowel or gall bladder?
*
First Choice
Second Choice
f) Any complaint or tendency that any necessitate such consultationor treatment in the future?
*
First Choice
Second Choice
Are there any additional facts affecting the proposed insurance which shouldbe disclosed to insurers?
*
First Choice
Second Choice
Have you any intention of engaging in winter sports or pastimes renderingyou liable to personal injury?
*
First Choice
Second Choice
Submit
*are mandatory fields.