APPLICATION FOR TRAVEL INSURNANCE
"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 ARTICLE 20 OF THE INSURANCE LAW OF THE KINGDOM OF CAMBODIA OR ANY SUBSEQUENT AMENDMENT THEREOF.  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.
PROPOSER DETAILS
Particular of Proposer
Name:* Passport:*
DoB:* Phone:*
Address:*
Occupation: Company:
Email:* Telephone:
Beneficiary: Phone:
Particulars of accompanying children travelling with
Number of Children: under 16 years old
No. Name Passport # Date of Birth
1
2
3
4
TRIP DETAILS
Policy Duration (Number of Days)
Commencing Date:* Returning Date:* Your traveling period is
NOTE*: MUST DEPART FROM CAMBODIA AND RETURN BACK TO CAMBODIA
Itinerary (please select country in order of your trip):*
Your travel itinerary summary:
COVER PLAN AND PREMIUM
Cover Plan

PREMIUM: (USD)
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:
NOTE1: The insurance you are applying for is in acordance 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 condtions state within.
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.
Go to Traveler's Insurance page for view of policy wording

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