TRAVEL INSURANCE – Heirs Forms

TRAVEL INSURANCE KYC FORM

IMPORTANT

“An Insurance Agent who assists an applicant to complete application or proposal form for insurance shall be deemed to have done so as the agent of the applicant – Section 54 (2) Insurance Act, 2003”.

Please Answer ALL questions in full. Use CAPITAL LETTERS

CUSTOMER'S DETAILS

Surname: (*)

First Name: (*)

Other Names:

Contact Address: (*)

Nationality: (*)

Profession: (*)

Email Address: (*)

Telephone No.: (*)

Int'l Passport No.: (*)

Passport Valid Until: (*)

Passport Issuing Country: (*)

Travel Destination (Country): (*)

Purpose of Travel: (*)

Insurance Plan Type: (*) Please select an option from either of the three categories.

Standard Protection: TravellerPearlFamilyEuropeEconomy

Student Protection: Students EconomyStudents ClassicStudents Premium

Pilgrimage Protection: Pilgrimage Protection BasicPilgrimage Protection PlusPilgrimage Protection Extra

Insurance Period From: (*)

To: (*)

Are you suffering from any sickness/disease/ailment under treatment? (*)

Next of Kin: Name: (*)

Contact Address: (*)

Applicant's Confirmation: (*)
By checking this box, you acknowledge that the information you have provided is true, accurate, and complete to the best of your knowledge. You also understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability

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