|
THE PROPOSER |
|
A) Name |
|
|
B) Title |
|
|
C) Postal Address |
|
|
D) Work Phone |
|
|
E) Home Phone |
|
|
F) E-mail |
|
|
G) Period of Journey |
|
|
From |
|
|
To |
|
|
H) The Journey From: |
|
|
I) Do you wish to extend cover to include medical
expenses in the USA and Canada? |
|
|
|
|
|
PERIOD OF INSURANCE: |
|
Number of Days |
Day(s) |
|
Rates change for 31+ Days |
|
|
|
|
PERSONAL ACCIDENT: (Standard amount of cover: $10,000 = 1 Unit, Maximum
40 Units))
Cover per person: $100,000 - Ages 15-70 and $1,000 - Ages under 15 |
|
A) Normal Benefits |
|
|
B) Capital Benefits Only |
|
|
C) Death Benefits Only |
|
|
|
|
|
MEDICAL AND OTHER EXPENSES: (Standard amount of cover $15,000 maximum
$75,000) |
|
A) $15,000 |
|
|
B) $20,000 |
|
|
C) $30,000 |
|
|
D) $40,000 |
|
|
|
|
BAGGAGE/PERSONAL LUGGAGE: (Value of personally accompanied luggage,
minimum sum insured is $1,000 per person, child under age of 15, $500, Maximum
amount for cover is $15,000)
Rates are increased for USA and Canada |
|
|
|
Available for travel anywhere in the World by land and sea and air as a
passenger in an aircraft operated by a regular airline or established charter
service.
Automatic extension granted if transport service is delayed by circumstances
outside control of the insured person. |
|
|
|
|
|
|
|
|
|
|
|
|