INTERNATIONAL TRAVEL INSURANCE

  • PLEASE COMPLETE THIS FORM IN BLOCK LETTERS

  • (A) PERSONAL DETAILS

  • eg: 2 June 1993
  • Period of Insurance:

  • eg:10 January 2021
  • eg: 31 June 2022
  • (B) DISCLOSURE

  • DECLARATION

    I declare that to the best of my knowledge and belief, the information given above is true and that all Health Conditions and Material Facts have been disclosed to the underwriters. I agree that this application shall be the basis of the Contract of Insurance. I understand that non-disclosure or misrepresentation of a material fact constitutes inadmissibility of The Company’s liability.
  • Date Format: MM slash DD slash YYYY
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