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    Application Form (PDF Version) - Travel - 2018-06 (June 1)

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    fetid
    This document is an application form for travel insurance through Pacific Cross Insurance. It requests information such as the applicant's name, address, contact details, passport number, trip details, and personal information for any additional persons to be insured. The applicant certifies that the information provided is true and complete. They understand the terms, conditions, and exclusions of the policy. The applicant consents to Pacific Cross collecting and using their personal data in accordance with privacy laws.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Application Form (PDF Version) - Travel - 2018-06 (June 1)

    Uploaded by

    fetid
    310 views2 pages
    This document is an application form for travel insurance through Pacific Cross Insurance. It requests information such as the applicant's name, address, contact details, passport number, trip details, and personal information for any additional persons to be insured. The applicant certifies that the information provided is true and complete. They understand the terms, conditions, and exclusions of the policy. The applicant consents to Pacific Cross collecting and using their personal data in accordance with privacy laws.

    Original Description:

    TravelSafe Insurance Application Form

    Original Title

    Application Form (PDF Version)_Travel_2018-06 (June 1)

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    © © All Rights Reserved

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    This document is an application form for travel insurance through Pacific Cross Insurance. It requests information such as the applicant's name, address, contact details, passport number, trip details, and personal information for any additional persons to be insured. The applicant certifies that the information provided is true and complete. They understand the terms, conditions, and exclusions of the policy. The applicant consents to Pacific Cross collecting and using their personal data in accordance with privacy laws.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    310 views2 pages

    Application Form (PDF Version) - Travel - 2018-06 (June 1)

    Uploaded by

    fetid
    This document is an application form for travel insurance through Pacific Cross Insurance. It requests information such as the applicant's name, address, contact details, passport number, trip details, and personal information for any additional persons to be insured. The applicant certifies that the information provided is true and complete. They understand the terms, conditions, and exclusions of the policy. The applicant consents to Pacific Cross collecting and using their personal data in accordance with privacy laws.

    Copyright:

    © All Rights Reserved
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    TRAVELSAFE INSURANCE

    TRAVELSAFE INSURANCE
    APPLICATION
    APPLICATION FORM
    FORM

    For Pacific Cross use only: This Application Form was issued with Official Confirmation of Coverage (OCC) Number: _______________________
    or Group Policy Number: ________________

    TRIPGUARD INDIVIDUAL TRIPGUARD FAMILY ANNUAL SHORTSECURE (Non-Air Domestic)

    Travel Including USA/Canada HKG Travel Excluding USA/Canada HKG Philippine Travel Only Individual Group

    Name of Applicant:
    Address: Office Home

    (Landline
    Tel. No.: or Mobile) E-mail Address:
    Occupation: Nationality: Civil Status: Gender: M F

    Principal Applicant’s Passport No.: or TIN/SSS/Driver’s License I.D. No.:


    Principal Applicant is included in the Persons to be insured? YES NO if yes, include your details in the “Persons to be insured“ table
    Purpose of Trip: Visit Relatives Business (i.e., attending conference or meeting) Short-term Study Leisure Others (Pls. specify.)

    BIRTHDATE CITY/TOWN ADDRESS ID TYPE/NO. RELATIONSHIP


    PERSONS TO BE INSURED (State only if different from PLAN (State only if different BENEFICIARY
    (mm/dd/yyyy)
    Applicant’s address) from Applicant’s ID) TO INSURED

    If space is insufficient, please use back page. However, continue to indicate total premium at the front.
    E
    MODE OF PAYMENT: CASH CHECK CREDIT/DEBIT CARD TOTAL COST
    (Please leave blank if you are applying for an Annual Plan.)
    ITINERARY:

    COVER TO COMMENCE FROM TO FOR DAYS


    month day year month day year

    The above statements are true and complete and all prospective Insured/s understand that no travel will be made for the purpose of obtaining medical treatment for any
    existing, recurring, congenital, medical and physical conditions. I understand that any Pre-Existing Medical Condition shall not be insured, unless stated covered in the Policy
    Schedule or Official Confirmation of Coverage. I understand and accept the Notes, Terms and Conditions indicated in this Application Form and as stipulated in the Master Policy.
    I understand that the prospective Insured/s have personally applied for the travel insurance coverage. I hereby represent and confirm that the details stated herein are true and
    correct. By submitting this application form, I accept the conditions by which Pacific Cross will provide insurance coverage for the trip of all prospective Insured/s.
    I understand that under Republic Act 9160 (Anti-Money Laundering Act) as amended by Republic Act 9194 and pertinent regulations, all insurance companies are required
    to satisfactorily establish the identities of all its customers. Hence, Pacific Cross Insurance, Inc. reserves the right not to accept and process any application for insurance if the
    customer fails to provide sufficient evidence to establish his identity.
    I understand that any change in the above details should be made in writing and submitted to Pacific Cross prior to Policy commencement date. Otherwise, the Policy is enforced.
    DATA PRIVACY CONSENT: I understand that Pacific Cross collects and uses my personal data to service and administer my insurance policy, to provide appropriate and timely
    Medical and Travel Services, and for the purposes provided in the Pacific Cross Privacy Statement attached to this application form (also available at www.pacificcross.com.ph). By
    signing this application form, I acknowledge that I have read and agree to the terms of the Privacy Statement, and understand that my data may be collected, shared, disclosed,
    transferred, used or otherwise processed by Pacific Cross in accordance with the Data Privacy Act of 2012, its implementing rules and regulations, and the Privacy Statement.
    Nothing in this form is intended to revoke or supersede any prior consent that I have given to Pacific Cross in respect of the processing activities involving my personal data.

    I certify that I have validated the information in this


    application against the original I.D. card/s presented
    Signature over Printed Name of Applicant Date and in doing so, have established the applicant’s identity. Signature over Printed Name of Agent
    NOTE: This application forms part of the contract. For full details, please refer to the Master Policy. A copy is available for inspection at any Pacific Cross office or from your
    Agent. Notice of any claim must be given to the Company within 31 days from the expiration of this insurance or upon completion of events for which the claim is being made.
    MAXIMUM PERIOD OF COVERAGE: Up to 180 days per trip for Tripguard and 90 days per trip for Annual Plans, unless otherwise endorsed; up to five (5) days per trip for
    ShortSecure Group and 15 days per trip for ShortSecure Individual.
    PERIOD OF INSURANCE: Tripguard and Annual Plans commence seven (7) hours prior to the scheduled flight departure indicated in your travel ticket, or the specified effective
    date applied for, whichever is later and ends on: (a) the indicated expiry date/expiry of the 90-day limit per trip or (b) upon return to the place of residence or employment or
    (c) after seven (7) hours upon actual arrival at the airport terminal premises of the Country of Origin, whichever occurs first. ShortSecure Non-Air Domestic Plans commence
    at the departure time from the Point of Origin which may be the accommodation site such as place of residence or employment, hotels, universities or schools or the terminal
    wherein the transport vehicle to be used for the land or water trip will set off and ends on the indicated expiry date or upon arrival at the Point of Origin, whichever occurs first.

    REMARKS
    (for Pacific Cross use only):
    Pacific Cross Center, 8000 Makati Avenue, 1200 Makati City, Metro Manila, Philippines
    Page 1 of 2 T +63 2 230-8511 F +63 2 230-8570 E client_services@pacificcross.com.ph W www.pacificcross.com.ph

    Here for You V06.18


    Use this page if space on the front page is insufficient. However, please continue to indicate the total premium at the front.

    PERSONS TO BE INSURED BIRTHDATE CITY/TOWN ADDRESS


    (State only if different from PLAN
    ID TYPE/NO.
    (State only if different BENEFICIARY
    RELATIONSHIP
    (mm/dd/yyyy)
    Applicant’s address) from Applicant’s ID) TO INSURED

    Page 2 of 2 TRAVELSAFE INSURANCE APPLICATION FORM V06.18

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