Anjo Insurances
Travel Insurance Quote
Application Form

Please provide the following contact information:

THE PROPOSER
A) Name
B) Title
C) Postal Address
D) Work Phone
E) Home Phone
F) E-mail
G) Period of Journey
From
To
H) The Journey From:
I) Do you wish to extend cover to include medical expenses in the USA and Canada?	No Yes
PERIOD OF INSURANCE:
Number of Days	1 2 3 4-10 11-18 19-24 25-31 31+ Day(s)
Rates change for 31+ Days
PERSONAL ACCIDENT: (Standard amount of cover: $10,000 = 1 Unit, Maximum 40 Units)) Cover per person: $100,000 - Ages 15-70 and $1,000 - Ages under 15
A) Normal Benefits
B) Capital Benefits Only
C) Death Benefits Only
MEDICAL AND OTHER EXPENSES: (Standard amount of cover $15,000 maximum $75,000)
A) $15,000	No Yes
B) $20,000	No Yes
C) $30,000	No Yes
D) $40,000	No Yes
BAGGAGE/PERSONAL LUGGAGE: (Value of personally accompanied luggage, minimum sum insured is $1,000 per person, child under age of 15, $500, Maximum amount for cover is $15,000) Rates are increased for USA and Canada
Available for travel anywhere in the World by land and sea and air as a passenger in an aircraft operated by a regular airline or established charter service. Automatic extension granted if transport service is delayed by circumstances outside control of the insured person.