TRAVEL INSURANCE FORM

PHOENIX TRAVEL SAFE INSURANCE PROPOSAL FORM
DETAILS OF CLIENT
SURNAME
surname
FIRST NAME
first name
OTHER NAME
NATIONALITY
GENDER
DOB
PASSPORT NUMBER
DESTINATION
DATE OF DEPARTURE

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
DATE OF RETURN

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PERMANENT RESIDENCE
POSTAL ADDRESS
TELEPHONE NUMBER
020-000-0000Format: (000) 000-0000.
EMAIL
ama@gmail.com
FLIGHT DETAILS
NAME OF AIRLINE
PORT OF DEPARTURE
TRANSIT
PURPOSE OF TRIP
NEXT OF KIN DETAILS
NAME
RELATIONSHIP
TELEPHONE NUMBER
020-000-0000Format: (000) 000-0000.
POSTAL ADDRESS
EMAIL
ama@gmail.com
POLICY CANCELLATION/AMENDMENT OF FOREIGN TRAVEL POLICY
Policy holder is entitled to 70% of premium as refund for cancelled policies. However, notification of cancellation should be done before the commencement of the policy. Failure to do so will render the refund null and void.
DECLARATION
I hereby certify, represent and warrant that: (i) I have read the foregoing statement or they have been read to me, and I understand them, (ii) I am (we are) eligible to participate in this insurance program, (iii) I am (we are) currently in good health and have not been diagnose with, treated for, and do not suffer from any pre-existing or other medical condition which I (we) foresee may require treatment in the future or for which I (we) intend to claim under this insurance. If signed as proxy of the insured, the undersigned warrants their authority and capacity to so act and to bind the insured. By acceptance or coverage, the insured ratifies the authority signatory to bind insurance.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Proposer
Agent
Should be Empty:

PHOENIX TRAVEL SAFE INSURANCE PROPOSAL FORM

DETAILS OF CLIENT

FLIGHT DETAILS

NEXT OF KIN DETAILS

POLICY CANCELLATION/AMENDMENT OF FOREIGN TRAVEL POLICY

DECLARATION