AIG Assist Short-Term Travel Insurance
 Application Form
  I wish to apply for the Travel Insurance for myself as the following statements below:
  1. Name of applicant:
       
    Address:
     
       
    Tel:
       
    Occupation:
       
    Age:
       
    Name of Beneficiary:
       
    Relationship:
       
  2. Insurance Plan Selected (please tick):  
       
    Personal Plan Comprehensive Plan
       
   

Age 1 - 70 Years

 Age 1 - 70 Years
       
    Age 71 - 85 Years Age 71 - 85 Years
       
  3. Duration: Up to days
       
    Effective From:
       
    Flight No:   Dep:  a.m. / p.m.
       
    Country of Destination:
       
    Purpose of Trip:
       
    Premium: Baht
       
       
       
    _____________________________________  
                        Signature  
       
     
                    Date  
       
       
    REMINDER OF THE OFFICE OF INSURANCE, MINISTRY OF COMMERCE: Give answers to questions above truthfully otherwise the company may have cause to deny liability under the policy in accordance with section 865 of the Civil & Commercial code.
       
    This insurance is non-changeable and no refund is made after effective of policy