International Travel InsuranceFugen International2021-09-23T16:38:35+00:00 INTERNATIONAL TRAVEL INSURANCE PLEASE COMPLETE THIS FORM IN BLOCK LETTERS(A) PERSONAL DETAILSSurname: Other Names: Gender (please tick): Male Female Date of Birth:* eg: 2 June 1993Occupation: Period of Insurance:Start Date:* eg:10 January 2021End Date:* eg: 31 June 2022Address in Ghana: Telephone:Email Country(ies) of Destination: Destination Address: Destination telephone:Passport Number: Issuing Country: Nationality: Beneficiary of Applicant: Relationship to Applicant: (B) DISCLOSUREAre you aware of any circumstances, medical or otherwise that could result in a claim under this instance? Yes No If yes, please provide detailsYesNoIf yes, please provide details DECLARATIONI 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. Signature of Applicant:Date MM slash DD slash YYYY Attach Travel PassportMax. file size: 512 MB.EmailThis field is for validation purposes and should be left unchanged.
