8/15/2019 Travel Guard Travel Insurance - Individual
(27062010).doc
1/1
Corporate Information Travel Sdn Bhd (144126-D)B-1-3, (1/F,
Block B), Northpoint Offices, Mid Valley City1 Medan yed !"tra
#tara, $%&'' "ala "*p"r, Malaysia
+ '3-&'%1 %%&& F '3-&'%1 %%&%
. 0cit0trael APPLICATION FORM
Notes: Neither the brochure nor this application form is a
contract of insurance. The specic terms, conditions applicable to
theinsurance are set out in the Policy.
CHARTIS TRAVEL !AR" TRAVEL INS!RANCE # IN"IVI"!AL
PLAN
Period of In$%ran&e''
"epart%re "ate' ( O&to)er *+,- Ret%rnin. "ate' ,(
O&to)er *+,- Total No/ of da0$' ,+
Itinerar0 ' ( O&t' Penan. 1 2L 1Fran3f%rt ,( O&t/'
Fran3f%rt 1 2L 4 Penan.
T0pe of plan (please tick one)'
+rael 2"ard !re*ier +rael 2"ard "perior +rael 2"ard
o*estic
+rael 2"ard !re*ier (4nn"al) +rael 2"ard "perior (4nn"al)
Area of &overa.e 5 please tick one)'
Re.ion , (4"stralia, Br"nei, Ca*5odia, China, "5ai, 6ndia,
6ndonesia, 7apan, orea, aos, Maca", Malaysia (8astto .est Malaysia
or ice-ersa), Maldies, Myan*ar, Ne 9ealand, !akistan, !hilippines,
in:apore, ri anka,+aian, +hailand, Vietna*)
Re.ion * (.orldide; e#?6 4M4?#6N
"ate of Birth 1@ 8C8MB8? 1%A NRIC 8 Pa$$port No/ 9:,*,; +* ((ith
thein$%red
.6F8 ender F8M48
Per&enta.e 5?7 1''D Conta&t No/ '1% @11@1
----------------------------------------------------------------------------------------------------------------------------------------------------------------For
office use only:
Re$ervation Offi&er' @!S "ate' Poli&0 No'
http://www.cit.travel/http://www.cit.travel/http://www.cit.travel/
