Application for Personal Accident Insurance

Insured

*Name:		Business Description:		Period of Insurance:	From: To:
Address:

Customer Details

*Company/Organization Name:

*Phone:

Fax:

*Email:

Interest Insured

Name	Sum Insured	Medical Expense
	US$	US$

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Territorial Limit

Nationwide and 24 hours
Worldwide and 24 hours
Working hours, Work related including traveling to and from workplace within Cambodia

History

Currently, does the proposer have any group personal accident policy? Yes No

Claim Experience

Has the proposer made any claim(s) or had any accident(s) for the past 3 years? Yes No

Remarks

Go to Personal Accident Insurance page for more information.


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