Application for Traveller’s Insurance

"Fill in the form below duly completed and submit to Forte Insurance (Cambodia) Plc. via the website. Please type clearly in Capital letters"
STATEMENT PURSUANT TO ARTICLE 20 OF THE INSURANCE LAW OF THE KINGDOM OF CAMBODIA OR ANY SUBSEQUENT AMENDMENT THEREOF.
YOU ARE TO DISCLOSE IN THIS PROPOSAL FORM, FULLY AND FAITHFULLY, ALL THE FACTS WHICH YOU KNOW OR OUGHT TO KNOW, OTHERWISE THE POLICY ISSUED HEREUNDER MAY BE VOID.
Particular of Proposer
Particulars of accompanying children travelling with proposer
Number:
NamePassport #Date of Birth
(under 16 years old)
Policy duration (number of days required)
*Commencing Date:*Returning Date:
Itinerary (please select country in order of your trip)
Asia Pacific
Schengen
Worldwide
  • , please state:
Remark
Cover level and Premium (please tick one option only)
Super Plan:
Standard Plan:
Declaration
I hereby declare that to the best of my knowledge there is no reason why the proposed travel should have to be altered or cancelled. I agree to accept the terms, exclusions and conditions as set out in the policy.
Date:Acct. No:
(official use only)
Cert. No:

NOTE1: The insurance you are applying for is in accordance with the policy wording. You should examine the wording of the policy document carefully before you complete your application to ensure the cover meets your needs, as you will be bound by the terms, exclusions and conditions state within.

NOTE2: Payment must has been made at Forte Insurance located at 325, Mao Tse Toung Blvd. Applicants will be given the Traveler's certificate after payment has been made. Travelers certificate is a verification that your travel policy is in force and must be collected before travel is made.

Go to Traveller’s Insurance page for view of policy wording