Client

ID #

Policy
No.

INCREASED MEDICAL PLAN

  100 C. Palanca Jr.

Assi Street
Legaspi Village,
st Makati City 1229
P.O. Box 2238,
Makati, Philippines
Tel. No. 528 –
Global 5400 / Fax No.
Travel 878 – 5555
Protecti
on

APPLICAT
ION FORM
for
OVERSEA
S TRAVEL
INSURAN
CE

This
applicatio
n provides
details of
your AIG
Assist
Plan
underwritt
en by
Philam
Insurance
Company,
Inc. It
forms part
of your
certificate
of
insurance
and is
subject to
the
exclusions
, terms
 and
conditions
of the
actual
Policy.
You are
required to
disclose in
this
applicatio
n form,
fully and
faithfully,
all the
facts
which you
know or
ought to
know.
Please
print
legibly.
You are
also
required to
submit a
copy of an
identificati
on card
with a
photo and
signature,
unless you
have
already
provided
Philam a
copy for
previous
applicatio
ns in any
of our
product
lines.

NAME OF
APPLICA
NT

La First M
st Name i
N d
a d
m l
e e
I
n
i
t
i
a
l
RESIDEN PERMAN
CE ENT
ADDRES ADDRES
S S (please
complete
only if
other
than
RESIDE
NCE)
Street Street

Province / Zi Province Z
City p / City i
C p
od C
e o
d
e
RESIDEN DAYTIM
CE E
PHONE PHONE
NO. NO.
DATE OF PLACE
BIRTH OF
(MM/DD/Y BIRTH
YYY)
TIN / SSS NATION
/ GSIS ALITY
No.
NATURE
OF SOURCE
WORK / OF
SELF-EM FUNDS
PLOYME
NT
If If
Employe Self-emp
d, Name loyed,
of Nature of
Employer Busines
s

PREFER R Ot
RED es he
MAILING id r
ADDRES en (p
S ce le
as
e
in
di
ca
te
be
lo
w)
Street Province Z
/ City i
p
C
o
d
e

FOR
FAMILY
COVERA
GE

NAME OF
SPOUSE

La First M
st Name i
N d
a d
m l
e e
I
n
i
t
i
a
l
DATE OF OCCUPA
BIRTH TON
(MM/DD/Y
YYY)

NAME(S) D
OF A
ACCOMP T
ANYING E(
DEPEND S)
ENT O
CHILD(R F
EN) ​(Last BI
Name, R
First T
Name, H
Middle
(M
Initial)
M/
D
D/
Y
Y
Y
Y)

BENEFICI R
ARY (IES) E
L
A
 TI
O
N
S
HI
P

PERSON
TO
CONTAC
T IN
CASE OF
EMERGE
NCY
RELATIO TELEPH
NSHIP ONE NO.

TRIP
INFORMA
TION

DEPART R N
URE E O.
DATE T O
U F
R D
N A
D Y
A S
T
E

DESTINA P T
TION U O
R T
P A
O L
S P
E R
O E
F MI
T U
RI M
P D
U
E
PREMIUMS (Philippine Pesos)

Worldwide Worldwide
Period
Insured Only Family Plan

1 to 4 days 451 1,099

5 to 6 days 712 1,750

7 to 8 days 986 2,435

 9 to 10 days 1,205 2,981

11 to 15 days 1,670 4,145

16 to 20 days 2,276 5,662

21 to 25 days 2,731 6,797

26 to 30 days 3,186 7,933

Additional week 453 1,102

* Premiums include documentary stamps and taxes

BENEFITS (Philippine Pesos)

COVERAGES
Medical Expense
Evacuation & Repatriation
Child Guard
Compassionate Visit
Trip Cancellation
Trip Termination
Flight Delay
Baggage Delay
Baggage and Personal Effects
Personal Accident
Loss of Travel Documents
Personal Liability
MAXIMUM BENEFIT
Up to 2,500,000 (deductible 500)
Unlimited
Travel costs plus up to 5,000 per day
Travel costs plus up to 5,000 per day
Up to 150,000 (deductible 500)
Up to 150,000 (deductible 500)
2,000 per 12 hours
Up to 5,000 per 12 hours
Up to 50,000, subject to limit of 7,000 for any one item
(deductible 500)
Up to 1,000,000
Up to 50,000
Up to 2,000,000

DECLARATIONS

APPLICANT AGENT / BROKER

I am/We are in good health, free from physical impairment or I hereby certify that I have validated the identification
deformity and I am/we are not traveling to receive medical document(s) provided by the applicant for the purpose of his
treatment. I/We understand that the maximum period of application for insurance.
coverage for any trip is 180 days.

I/We understand fully that if I am/we are below the age of 18

years or above the age of 70, I am/we are entitled only to
50% of the total Personal Accident Benefit. All other benefits
remain the same.

SIGNATURE DATE SIGNATURE OVER PRINTED DATE

NAME
NOTE: 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, Philam Insurance Company,
Inc. reserves the right to not accept and process any application for insurance if the customer fails to provide sufficient evidence to
establish his identity.