SCHEDULE OF BENEFITS

COVID-19 INSURANCE Limit (USD)
Policy Limit per Period of Insurance 50,000
Geographical Coverage Cambodia only
Covered Illness COVID-19 only
a) Hospital Room & Board (Overall daily max up to 90 days per disability)
  • i) Ordinary
  • ii) Intensive care Unit including equipments used in ICU (daily max up to 14 days)
75 per day
320 per day
b) COVID-19 Test (max $100 per test and max 4 times per disability) 400 per disability
c) Hospital Miscellaneous Services (daily max)
This benefit is inclusive of:
  • - Drugs, Medicine, Dressings, Ordinary Splints, Plaster Casts, and Intravenous Infusions;
  • - In-Hospital Physician’s fee and Nurse’s fee;
  • - The cost of Blood or Blood Plasma and its Administration;
  • - Physical Therapy;
  • - Prescribed Take Home Medicines
150 per day
d) Diagnostic Procedure (max $150 per time for all type of Diagnostic Procedure and max 3 times per disability)
This benefit is inclusive of: X-ray, Electrocardiograms, Basal Metabolism Test, Laboratory Examinations and Tests, Ultrasound, Endoscopy and Biopsy, CT Scan and MRI Scan
450 per disability
e) Emergency Hospital Transfer (max per disability)
  • - Air ambulance
  • - Ground ambulance
5,000 per disability
5 per disability
f) Funeral Expenses (per case) 1,500 per disability
g) Underlying Illness (max per disability) 150 per disability
COVID-19 INSURANCE
新冠病毒 医疗保险
Please input in English
请用英文输入
PREMIUM
保费
USD
YOUR PERSONAL INFORMATION
你的个人信息

Please confirm that you:
请确认一下内容

Please attach COVID-19 certificate
请提供新冠病毒测试报告
DECLARATION OF TERMS & PAYMENT
申报和支付
  1. I declare that I have answered all of the above questions truthfully and to the best of my knowledge. If this form has been completed on my behalf, I agree to the truthfulness of the responses given. I understand that any incorrect or incomplete answer or the concealment of any facts relevant to this insurance may invalidate this policy. I understand that the insurer shall be entitled to retain all premiums paid during the policy year by virtue of breach of this declaration.
    我在此声明,在我所知的范围内,我已经如实回答了所有问题。如果该表格是以我的名义所填写,我同意所填写之内容的属实。我明白任何不正确或不完整的回答或隐瞒与本保险有关的任何事实均可能导致本保单失效,我亦明白,承保人有权保留因违反本声明而在保单年度内所支付的所有保费。
  2. I am also aware that I must notify the insurer of any material facts related to this insurance, which arise between the date of this declaration and the inception of this policy.
    我也知道,我必须将在本声明日与保单生效日期间的任何与本保险有关的重要事实告知保险公司。
  3. I understand and accept that for all Insured, no benefits will be payable for any pre-existing condition which is not approved by the insurer.

    我明白并接受被保险人对于未获得保险人批准的受保日前已存在的任何疾病,将不给予赔偿。

  4. I confirm that I am currently not in Cambodia or just arrived in Cambodia today.
    我确认我目前不在柬埔寨,或者我今天刚到柬埔寨
  5. I confirm that I currently have no signs or symptoms of COVID-19.
    我确认,我目前没有任何新冠病毒肺炎的迹象或症状。
  6. I confirm that I currently have Health Certificate indicating a COVID-19 negative status issued by competent health authorities of my residing country no more than 72 (seventy-two) hours from the departure time from my residing countries.
    我在此确认我目前所持有的“新冠病毒肺炎” 检测结果为阴性的健康报告是在我离境出发前72小时内由我居住国当局指定的主管医疗卫生机构出具的。