"Fill in the form below duly completed and submit to Forte Insurance
(Cambodia) Plc. via the website. Please type clearly in Capital letters"
     STATEMENT PURSUANT TO THE INSURANCE ACT
(CAP I/ARTICLE 20) YOU ARE TO DISCLOSE IN THIS PROPOSAL
FORM, FULLY AND FAITHFULLY, ALL THE FACTS WHICH YOU
KNOW OR OUGHT TO KNOW, OTHERWISE THE POLICY ISSUED
HEREUNDER MAY BE VOID.

 
  Particulars of Proposer

 
Policy duration (number of days required)
  Name*
  Passport*
  #

  Occupation*
  Date of
  Birth
  Address
  Mobile*   Office
  Tel No.
E-mail

  Particulars of accompanying children travelling with proposer
          Commencing*
        (Day/Month/Year)

Returning*
(Day/Month/Year)

  
 
 
  Itinerary  
 

  Cover level and Premium (please tick one option only)
 
No.   Name                     Passport #             Date of Birth

 
 
Super Plan:
Premium:US$
Standard Plan: Premium:US$
  Declaration
 

I hereby declare that to the best of my knowledge there is no reason
why the proposed travel should have to be altered or cancelled. I agree
to accept the terms, exclusions and conditions as set out in the policy.
 
Date (Day/Month/Year)  
Acct. No:
(Official use only) 		 
Cert. No:
 
NOTE1: The insurance you are applying for is in accordance with the
policy wording.You should examine the wording of the policy document
carefully before you complete your application  to ensure the cover meets
your needs, as you will be bound by the  terms, exclusions and conditions state within.

Go to Traveller's insurance page for view of policy wording

  


  NOTE2: Payment must has been made at Forte Insurance located
  at 325, Mao Tse Toung Blvd. Applicants will be given the Traveler's
   certificate after payment has been made. Travelers certificate is a
   verification that your travel policy is in force and must be collected
   before travel is  made.