Individual & Children (Please fill in section 1, 2)
Family (Please fill in section 1, 2, 3)
Hong Kong Resident(s):
Yes
No
Type of Travel:
One way
Round Trip
Destination(s):
Inception Date:
(yyyy/mm/dd)
Expiry Date:
(yyyy/mm/dd)
Section 1
Name of Insured Person 1:
Date of Birth:
(yyyy/mm/dd)
HKID / Passport No.:
Address:
Telephone No.:
(Home)
(Office)
Section 2
No. of Children Accompanying Insured Person 1:
Section 3
Name of Insured Person 2:
Date of Birth:
(yyyy/mm/dd)
HKID / Passport No.:
Premium Payment Account:
Primary Account:
HING MASKEDMASKED MASKED, Current A/C 601-000-0000-0
Credit Card
I hereby authorize CMB Wing Lung Insurance Co. Ltd to debit from my Credit Card account the premium of the cover type selected.
ONLY accept CMB Wing Lung Bank Credit Card for premium payment.
VISA MasterCard:
-
-
-
Card Expiry Date:
(yyyy/mm)
Name of Credit Card Holder:
Collection of Policy:
to be mailed to correspondence address
to be collected at
branch
Medical History:
Are you and your accompanying applicant(s) in good health, free from physical impairment or deformity and not travelling to receive medical treatment? (For Insured Person aged from 65 to 80, doctor's certificate of good health is required. Please apply at our office or branches.)
Yes
No
If No, please provide full details.
Declaration
1.
I/we understand that this Policy excludes all pre-existing conditions for which I/we received medical treatment, diagnosis, consultation or prescription during the 180 days preceding my/our trip.
2.
I/we further declare that to the best of my/our knowledge, there is no reason why the proposed travel should have to be altered or cancelled, I/we agree to accept the terms, exclusions and conditions as set out in the Policy.
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