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Quotation Request ACH - Individual

The document is an Individual Quotation Request Form for Allianz Care & Health, requiring personal information of the insured person and dependants. It includes options for selecting coverage plans, payment methods, and effective dates, as well as areas of coverage. The form also outlines various maximum annual limits and outpatient benefits available to the insured.

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mikegitonga70
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1 views

Quotation Request ACH - Individual

The document is an Individual Quotation Request Form for Allianz Care & Health, requiring personal information of the insured person and dependants. It includes options for selecting coverage plans, payment methods, and effective dates, as well as areas of coverage. The form also outlines various maximum annual limits and outpatient benefits available to the insured.

Uploaded by

mikegitonga70
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ALLIANZ CARE & HEALTH

INDIVIDUAL QUOTATION REQUEST FORM

INSURED PERSON
First Name : ...................................................................... Last Name : ..................................................................... Date of birth : ……/……../ ............................Nationality :……………………………….Gender (M/F) : .............
Residential address(1) :………………………………………………………………………………………………….ZIP Code : …………………City :..................................................................... Country : ...............................................

Email : ................................................................................................................... Tel. :………………………………………………………….…….…. Cell phone :…............................................................................................. .....

Correspondence Address (if different from the home address) :………………………………………………………………………………….ZIP Code : …………………City :....................................Country : ...............................................

Professional status :……………………………………………………………………………………………………………………………………………………………………………………………………………………………………….

DEPENDANTS TO BE INCLUDED IN THE PLAN CHOOSE YOUR PLAN


Date of Gender Country of usual
Relationship Last Name First Name )
birth (M/F) residence(1 Primary Vitality Prestige

1 Choose your Maximum Annual Limit :

US$ 25,000 US$ 50,000 US$ 200,000


US$ 300,000 US$ 500,000 US$ 4,500,000

2 Choose your level of coverage for Outpatient benefits :


(1) Country in which you and beneficiaries are living at least 6 months a year. (it will also apply to Maternity, Dental & Vision of chosen)

PAYMENT 80%of usual benefits 90%of usual benefits 100% of usual benefits
L’assistance rapatriement et évacuation médicale d’urgence est incluse.
How would you like to pay your premium (payment in dollars) ?
Annually C CHOOSE YOUR OPTIONS

Maternity
EFFECTIVE DATE OF COVERAGE
Dental

MENT
Vision
CHOOSE YOUR AREA OF COVERAGE Only available if Dental is also chosen

Area 1 Area 2 Area 3 Area 4 Area 5


TEBrazil,
D’EFFETChina, ATEArgentina,
D DATE D’EFFET DATE
Australia, D’EFFET
South Saudi Arabia, Rest of Africa, Rest CHO DATE D DA CHOISISSEZ
Africa, __________________________________________________ VOS
’EFFE DATE D’EFFET T DE GARANTIES TE D’EFFET
FORMULES ’EFFET
Hong Kong, Belarus, Bosnia, Germany, Belgium, Bahrain, Egypt, of Asia (Bangladesh,
Macau, Switzerland Canada, Colombia, Chile, Denmark, United Arab Cambodia, North
+ countries in areas Spain, Ireland, Israel, Italy, Finland, France, Emirates, Iran, Iraq, Korea, India,
2, 3, 4 et 5. Japan, Mexico, Monaco, Greece, Hungary, Jordan, Kuwait, Indonesia, Laos,
United Kingdom, Russia, Iceland, New Lebanon, Oman, Qatar, Malaysia, Mongolia,
Singapore, South Korea, Caledonia, New Rest of Middle East, Myanmar,
VenezuelaCHOISISSEZ
+ countries in Zealand, Portugal, Syria,Turkey, Yemen Philippine
VOS OPTIONS
Rest of Latin + countries in area 5. s, Sri
Areas 3, 4, and 5.
America, Rest of Lanka, Vietnam,
Europe, Sweden etc.).
+ countries in areas
4,and 5.

ALLIANZ INSURANCE COMPANY OF KENYA LIMITED, P. O Box 66257-00800 Nairobi, Kenya

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