TRAVEL HEALTH INSURANCE PLAN

Complete and submit this Online Application Form


Travel Health Insurance Plan Application Form


  • PART ONE:  CONTACT DETAILS

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  • PART TWO:  POLICY EFFECTIVE DATE

  • PART THREE:  DETAILS OF INSURED PERSON(S)

  • PART FOUR:  AUTHORIZATION AND DECLARATION

  • Note: Credit Card must be valid over 12 months.
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  •  I hereby authorize INTERNATIONAL ADMINISTRATORS LIMITED, the third party administrator of PACIFIC CROSS INSURANCE COMPANY LIMITED to debit the premium from my credit card account for the insurance policy.
  • I hereby apply for a Travel Health Insurance Policy to be based on the above statements, and warrant that to the best of my knowledge and belief that no Insured Person is travelling contrary to the advice of a medical practitioner or for the purpose of obtaining medical treatment and that I understand any illnesses or accidents treated within six months prior to applying insurance are not covered. I further warrant that I am not aware of any illnesses or complaints at the time of applying insurance.