Traveller's Insurance

APPLICATION FOR TRAVEL 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.

TRIP DETAILS

Policy Duration (Number of Days)

Departure Date *

Return Date *

Your traveling period is

NOTE*: MUST DEPART FROM CAMBODIA AND RETURN BACK TO CAMBODIA

Itinerary (please select your destination):*

COVER PLAN AND PREMIUM

Cover Plan

Standard Plan SUPER PLAN

Section	Benefit and Limit Type	Standard Plan (US$)
I	Overseas medical and additional expenses	50,000
II	24-hour emergency medical assistance and services	Same benefits for each insured person; details as specified in the policy
III	Accidental death and permanent disablement	30,000
IV	Baggage and personal effects	1,500
V	Loss of personal money	300
VI	Personal liability	250,000
VII	Loss of deposits and cancellation charges	3,000
VIII	Hijack	1,500

Premiums
Region	Standard Plan (US$)
ASEAN COUNTRIES
1 - 3 days	7
4 - 6 days	9
7 - 10 days	12
11 - 14 days	16
Premium per day	1.20
Asia Pacific and Schengen
Premium per day	2
More than 60 days – rate per week	10
Minimum premium	21
Worldwide (excluding USA and Canada)
Premium per day	3
Minimum premium	35
USA and Canada
Premium per day	3.60
Minimum premium	42

Section	Benefit and Limit Type	SUPER PLAN (US$)
I	Overseas medical and additional expenses	100,000
II	24-hour emergency medical assistance and services	Same benefits for each insured person; details as specified in the policy
III	Accidental death and permanent disablement	60,000
IV	Baggage and personal effects	3,000
V	Loss of personal money	600
VI	Personal liability	500,000
VII	Loss of deposits and cancellation charges	6,000
VIII	Hijack	3,000

Premiums
Region	SUPER PLAN (US$)
ASEAN COUNTRIES
Premium per day	4
Minimum premium	35
Asia Pacific and Schengen
Premium per day	4
More than 60 days – rate per week	-
Minimum premium	35
Worldwide (excluding USA and Canada)
Premium per day	5
Minimum premium	45
USA and Canada
Premium per day	6
Minimum premium	54

APPLICANT DETAILS

Applicant Details

Name*

Passport*

Date of Birth*

Phone*

Address*

Email*

Beneficiary's Name

Beneficiary's Number

Details of accompanying children travelling with.

Number of children under 16 year olds:

No.	Name*	Passport #*	Date of Birth*	Age
1
2
3
4