Please fill out the form below to request a
quotation.
(All fields marked with
*
must be
completed)
Click here to Download this Proposal in PDF format
(Soon).
|
|
Personal Details: |
| Insured Full Name: |
|
| Email: |
* |
| Address / P.O.Box: |
|
| City: |
|
| Contact Number: |
* |
| Fax Number: |
* |
| Gender: |
|
|
Nationality: |
|
| Date of Birth: |
|
|
Country of Residence: |
|
|
|
|
Travel Details: |
|
Date of Departure: |
|
|
Period of Travel: |
5 days
9 days
15 days
22 days
31 days
45 days
62 days
92 days
Annual |
|
Destination: |
Worldwide Excluding USA and Canada
Worldwide |
|
Country to be Visited: |
|
|
Cover required: |
Medical
Travel Inconvience
Adventure Sports Extension
Terrorism Cover Extension |
|
Additional Members: |
1st member:
(Full name, Nationality, Gender and Date of
birth) |
|
2nd member:
(Full name, Nationality, Gender and Date of
birth) |
|
3rd member:
(Full name, Nationality, Gender and Date of
birth) |
|
4th member:
(Full name, Nationality, Gender and Date of
birth) |
|
5th member:
(Full name, Nationality, Gender and Date of
birth) |
|
|
|
|
Declaration: |
|
(i) There are no
circumstances connected with the holiday which
render it abnormal
(ii) All persons to be insured are in good
health
(iii) There are no reasons of which I am aware
why the planned holiday would be cancelled or
curtailed
I hereby subscribe to AXA Travel Smart of which
Terms and Conditions I have read understood and
agreed |
| |
|
