SCHEDULE OF BENEFITS

COVID-19 INSURANCE Maximum Limit (USD)
Maximum Limit per Period of Insurance 50,000
Covered Illness COVID-19 only
a) Hospital Room & Board (Overall daily max up to 90 days per disability)
  • i) Ordinary
  • ii) Intensive care Unit including equipments used in ICU (daily max up to 14 days)
75 per day
320 per day
b) COVID-19 Test (max $100 per test and max 4 times per disability) 400 per disability
c) Hospital Miscellaneous Services (daily max)
This benefit is inclusive of:
  • - Drugs, Medicine, Dressings, Ordinary Splints, Plaster Casts, and Intravenous Infusions;
  • - In-Hospital Physician’s fee and Nurse’s fee;
  • - The cost of Blood or Blood Plasma and its Administration;
  • - Physical Therapy;
  • - Prescribed Take Home Medicines
150 per day
d) Diagnostic Procedure (max $150 per time for all type of Diagnostic Procedure and max 3 times per disability)
This benefit is inclusive of: X-ray, Electrocardiograms, Basal Metabolism Test, Laboratory Examinations and Tests, Ultrasound, Endoscopy and Biopsy, CT Scan and MRI Scan
450 per disability
e) Emergency Hospital Transfer (max per disability)
  • - Air ambulance
  • - Ground ambulance
5,000 per disability
5 per disability
f) Funeral Expenses (per case) 1,500 per disability
g) Underlying Illness (max per disability) 150 per disability
* No cover is provided if the COVID-19 test is negative.
* No cover is provided for quarantine or isolation.
COVID-19 INSURANCE
PREMIUM
USD
YOUR PERSONAL INFORMATION

Please confirm that you:

Please attach COVID-19 certificate
DECLARATION & PAYMENT
  1. I declare that I have answered all the questions truthfully and to the best of my knowledge. If this form has been completed on my behalf, I agree to the truthfulness of the responses given. I understand that any incorrect or incomplete answer or the concealment of any facts relevant to this insurance may invalidate this policy, I also understand that the insurer shall be entitled to retain all premiums paid during the policy year by virtue of breach of this declaration.
  2. I am also aware that I have to notify the insurer of any fact material to this insurance, which arises between the date of this declaration and the inception of this policy.
  3. I understand and accept that for all Insured, no benefit will be payable to any pre-existing condition which is not approved by the Insurer.
  4. I confirm that I am currently not in Cambodia or Just arrive Cambodia Today
  5. I confirm that I currently have no any sign or symptom of COVID-19
  6. I confirm that I currently have health certificate confirm COVID-19 negative within 72 hours