AIG Assist ™ Enrolment Form  
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Please print, fill up form and fax/mail to Misa Travel

 Office Address :
MISA TRAVEL PTE LTD,
Blk 531A Upper cross Street,
#03-106, Singapore 051531
Tel (65) 6538-0318
Fax (65) 65365895






Misa travel staff name : ___________________  
 
Insured Adult 1
Name: ________________________________________
D.O.B ( dd/mm/yyyy ): _____________________
NRIC/PP: __________________________ Email:_________________________
Address:
( S'pore )		 ______________________________________________________________
Postal Code: _________________________ Tel No: (H)_______________________
Tel No: (O) _________________________ Tel No: (Hp)______________________
 
Insured Adult 2 (Applicable for Family Plan Only)
Name: __________________________________________
D.O.B ( dd/mm/yyyy ): _________________________
NRIC/PP: ________________________ Email:_________________________
Address:
( S'pore )		 ______________________________________________________________
Postal Code: _________________________ Tel No:(H)_______________________
Tel No: (O) _________________________ Tel No: (Hp)______________________
For Family Plan, children must be unmarried and unemployed and must be no older than 18 years of age or up to 23 years if studying full-time in a recognised institution of higher learning. Each child must be related to at least one insured adult. For Annual Plan, each child must be the legal child of the insured adult(s). There is no limit to the number of accompanying children.
Number of Accompanying Children:     _____________
Please tick 4
Choice of Plan:
Individual Family
Choice of Benefit:
Premier Superior Classic
Area:
Asean Asia Worldwide
 
Single Trip: For any trip up to 182 days
Furthest Destination from Singapore: ________________________
Length of Trip: ______ (both days inclusive)
Date of Departure:
                 
( D D / M M / Y Y )
Date of Return:
                 
( D D / M M / Y Y )
Annual: For any trip up to 90 days per trip
Effective Date:
                 
( D D / M M / Y Y )
Expiry Date:
                 
  ( D D / M M / Y Y )
 
Total Premium Payable ( No GST Required ) S$ _______________________
 
 

Mode Of Payment
Cash Payment
Cheque Payment      Bank: ______________________   Cheque No: _______________________
Visa MasterCard  
For Visa / MasterCard, please indicate Card Expiry date and Card Account No below.

Card Expiry Date:
                 
( D D / M M / Y Y )

Card Account No:
                                     
NB: Policy will be issued upon receipt of approval from the respective credit card company.
 
Name of Insured Adult 1:   _______________________________________________________
Warranty and Declaration:
The Insured Person(s) hereby warrant and declare for themselves and on behalf of all members of the travelling party as follows:
  1. I/We are not travelling contrary to the advice of a Qualified Medical Practitioner or for the purpose of obtaining medical treatment.
  2. I/We are currently in good health, free from all physical impairment and deformity.
  3. I/We understand and agree that no insurance is in force until an Application is accepted by the Company and a Policy is issued pursuant thereon.
  4. I/We are aware of and agree to abide by the Policy's terms, conditions and exclusions.
  5. I/We agree and authorize any medical source (including hospitals and clinics), insurance officer or any other organization to release to the Company at any time any information concerning the Insured Person(s) if required.
    6.
Important Notice:
  1. Statement pursuant to the Insurance Act or any amendments thereof: You are to disclose in this application,  fully and faithfully, all the facts that you know or ought to know, otherwise, the policy issued  may be void and you may received nothing from the Policy.
  2. Neither the brochure nor the Application Form is a contract of insurance. However, your warranties, declarations and disclosures therein and herein shall form the basis of the Policy. The specific terms, conditions and exclusions applicable to the insurance are set out in the Policy, a copy of which is available upon request.
  3. Pre-existing medical conditions are not covered by the Policy.
    4.
 
Travel Agency : MISA TRAVEL PTE LTD Travel Agent's Name: ___________________________
 
_____________________________    ______________ ________________ ______________
Signature and Name of Insured Person or his/her Authorized Representative Date Producer Name Producer Code