8/15/2019 Travel Guard Travel Insurance - Individual (27062010).doc

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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'

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