SCHEDULE OF BENEFITS

COVID-19 INSURANCE Limit (USD)
Coverage:
In consideration of the payment of premium and the due observance and fulfilment of the terms and conditions of this Policy insofar as they relate to anything to be done or complied with by the Insured Person and subject to the terms, conditions, exclusions and memoranda contained herein or contained in the Certificate of Insurance, if the Insured Person is diagnosed Positive with COVID-19 by the laboratory authorized and appointed by the Ministry of Health Cambodia during the Period of Insurance within the Kingdom of Cambodia, INSURER will pay the Benefit to the Hospital.
Policy Limit per Period of Insurance 50,000
Geographical Coverage Cambodia only
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) 150 per day
d) Diagnostic Procedure (max $150 per time for all type of Diagnostic Procedure and max 3 times per disability) 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
COVID-19 INSURANCE
新冠病毒 医疗保险
Please input in English
请用英文输入
PREMIUM
保费
USD
YOUR PERSONAL INFORMATION
你的个人信息

Please confirm that you:
请确认一下内容

Last Flight Number arriving Cambodia (if you don't have flight number yet, please complete as TBA and email to covid-19@forteinsurance.com once you have the flight ticket)*
到达柬埔寨的最后一个航班号码(如果您还没有航班号码,请填写TBA ,并在您得知航班号码后立即发邮件给covid-19@forteinsurance.com
DECLARATION
声明
  1. I declare that I have answered all of the above 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 understand that the insurer shall be entitled to retain all premiums paid during the policy year by virtue of breach of this declaration.
    我在此声明,在我所知的范围内,我已经如实回答了所有问题。如果该表格是以我的名义所填写,我同意所填写之内容的属实。我明白任何不正确或不完整的回答或隐瞒与本保险有关的任何事实均可能导致本保单失效,我亦明白,承保人有权保留因违反本声明而在保单年度内所支付的所有保费。
  2. I am also aware that I must notify the insurer of any material facts related to this insurance, which arise between the date of this declaration and the inception of this policy.
    我也知道,我必须将在本声明日与保单生效日期间的任何与本保险有关的重要事实告知保险公司。
  3. I understand and accept that for all Insured, no benefits will be payable for any pre-existing condition which is not approved by the insurer.

    我明白并接受被保险人对于未获得保险人批准的受保日前已存在的任何疾病,将不给予赔偿。

  4. I confirm that I am currently not in Cambodia or just arrived in Cambodia today.
    我确认我目前不在柬埔寨,或者我今天刚到柬埔寨
  5. I confirm that I currently have no signs or symptoms of COVID-19.
    我确认,我目前没有任何新冠病毒肺炎的迹象或症状。
  6. I understand and accept that I will be responsible for any expenses that are not covered or exceed the limit of the Policy and will pay any uncovered or exceeded expenses to the Hospital directly before being discharged from the Hospital.
    我明白并同意,我将负责本COVID-19保险单未包括或超出限额的任何费用,并将在出院前直接向医院支付保险单未包括或超出的所有费用。
  7. I understand and accept that the COVID-19 Insurance Policy shall be non-renewable, non-endorsable and non-cancellable. The premium is not refunded in any cases.
    我明白并接受COVID-19保单是不可续保、不可背书、不可取消的,并且保费在任何情况下都是不可退还的。