Corporate Information Travel Sdn Bhd (144126-D)

B-1-3, (1/F, Block B), Northpoint Offices, Mid Valley City

1 Medan Syed Putra Utara, 59200 Kuala Lumpur, Malaysia
T : 603-2091 9922

F: 603-2091 9929

APPLICATION FORM

W: www.cit.travel

Notes: Neither the brochure nor this application form is a contract of insurance. The specific terms, conditions applicable to the
insurance are set out in the Policy.

CHARTIS TRAVEL GUARD TRAVEL INSURANCE_INDIVIDUAL PLAN

Period of Insurance::
Departure Date:
Itinerary :

5 October 2013

Returning Date:

15 October 2013

Total No. of days:

10

5 Oct: Penang KL Frankfurt 15 Oct.: Frankfurt KL - Penang

Type of plan (please tick one):

Travel Guard Premier

Travel Guard Superior

Travel Guard Premier (Annual)

Travel Guard Superior (Annual)

Travel Guard Domestic

Area of coverage (please tick one):

Region 1 (Australia, Brunei, Cambodia, China, Dubai, India, Indonesia, Japan, Korea, Laos, Macau, Malaysia (East
to West Malaysia or vice-versa), Maldives, Myanmar, New Zealand, Pakistan, Philippines, Singapore, Sri Lanka,
Taiwan, Thailand, Vietnam)
Region 2 (Worldwide* excluding Africa, Bangladesh, Canada, Middle East, Nepal, Tibet, USA)
Region 3 (Worldwide* including Africa, Bangladesh, Canada, Middle East, Nepal, Tibet, USA)
Insureds Information (All fields are compulsory)
Insured Name
(as per passport)

MOHD YUSRI KAMARUDDIN

Date of Birth

14 DECEMBER 1976

NRIC / Passport No.

761214 02 5585

Marital Status

MARRIED

Gender

MALE

Contact No.

019 5959418

Email

yusri@usm.my

Address

56 JALAN ANGGERIK 1/3, BANDAR AMANJAYA, 08000, SUNGAI PETANI KEDAH

Beneficiarys Information is optional. Insureds Estate shall be beneficiary, if no information is being furnished.
Beneficiary Full Name

NOR AZIRA ABD WAHAB

Date of Birth

6 JUNE 1976

NRIC / Passport No.

760606 08 5224

Relationship with the

insured

WIFE

Gender

FEMALE

Percentage (%)

100%

Contact No.

019 4181418

---------------------------------------------------------------------------------------------------------------------------------------------------------------For office use only:

Reservation Officer:

YUS

Date:

Policy No: