ACE Short Term Travel Insurance Application Form


ACE Short Term Travel Insurance Application Form

	I wish to apply for the Travel Insurance for myself as the following statements below:

	1.	Insured’s name-surname :

		Address:


		Phone No:

		Date of Birth:

		Passport No:

		Name of Beneficiary:

		Relationship:

	2.	Insurance Plan Selected (please tick):

		Personal Plan	Family Plan

		Economy Plan	Economy Plan

		Business Plan	Business Plan

		First Plan	First Plan

		Visa Plan	Visa Plan

	3.	Duration:	Up to days

		Effective From:

		Flight No:	Departure: a.m. / p.m.

		Country of Destination:

		Purpose of Trip:

		Premium:	Baht



		_____________________________________
		Signature


		Date


		REMINDER OF THE OFFICE OF INSURANCE, MINISTRY OF COMMERCE: Give answers to questions above truthfully otherwise the company may have cause to deny liability under the policy in accordance with section 865 of the Civil & Commercial code.

		This insurance is non-changeable and no refund is made after effective of policy