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Beer icR i cgicetelirl| CST haan TRAVEL GUARD CHARTISG. ss wASTUAUASAD ‘¢ruouidumausdeud / Benefit (In / Baht) ruhunsoo / Covage Pan A Pan B Pan ¢ Pan O 1. walsluimsiaston msqydeaic: cemvSomuarurrosdussdournqAiny, 5,000,000, 4,000,000 1,500,000 1,500,000 (net Aint of Pe irate 2. walsloaimsSnermereraurhalsann (ices! Fipene Incured Overs) «TAY 5,000,000, 3,000,000 2,000,000, 2,000,000 8 unlskuimsinrwerinatifdidatsnens tases! Sperse tered i Talon) - a2 250,000 150,000 70,000 40,000 4. walsloaithdursturndoseupoetisvarine (roxy Vstton) : TAN 250,000 150,000, 70,000 a 5 5000 18000 7.000 (Devas fat net Bet 2 6 walslowioruerinsAurluneriyndu (Enevony Tetwhone Cal Chapes): 28 500 300 20 100 7. walsleuimsndeuredemssarurv eqncunsemsndeuhanauisnniawy ‘herwRsO 4,000,000 2.000.000, 2.000.000 _ ets Cos (tone ot oom Pin TS 4 walsosinruteparnan poor Ln) Ter 4000000 | ao0na00 | so00000 so0000 8 walsioaimsieurSonsuanénmsiiuno (Tip Canostiton Fipens) TAG ‘srurueso ‘themuas0 sremunso : feiod Co | sei Cost | fen Cot 10. ualsieuiiinelumsanuowuhume satomstnsecdu ‘semusy semun50_ shemusy (eet Se ey et HHT feral Cost | Acta Cost | Al Cot 11, malsteudinwemsgeymoueatuibur (Las of Peso) 819 6.000 400 . 2 000 000 ‘mn0n0 (ao Le of ri aT 13. wausleuumsgytenSeroumemewonswwhro nsw 25,000 25,000 10,000 : (tg os ae Pty eg R om ad Dt) 4 14, wausTowlnowRpRSOUNENSMSAUMD (Loss of Tiavel Docamen) TALS 30,000 20,000 > - 15. weusleuimséetwomsabihure (Bayyage Doky) TAOS 35,000 25,000 2500 - 16, waleirearrere (i! es Geng) 5 15000 +000 5000 : 47. wastoubewensuddiumstumn (tro Doty) 452 35,000 25,000 2500 16. walsleuikcrufpesoensnineds wsiae B1-3U (oF Anantge) TA29 20,000 10,000 . a 19, waulsTovircrusuindouusndrngusnc (Rens! Vee Excess): TAI 25,000 20,000 15,000 - “Towbar $ wlsinarune whrabutidnecus lrudisietisen 300 ree aS yvaten 109 ves + Secor 1 gous taercsoerousare 110) ot S, coersqureven ‘ert he 1 Sao matt en he i 8 10) fo exh) omy ned we + Semhneal 2 wists apudeoc adorecnrsU auriiodelulsa® hneeorogssle tet gngilNs 5100 HL H eg eee + Sncvhste 1 scinneNCuna Lea AnererrAEY tor mORUNAAMemeamARArEREenirrrM 6) Gn ecm N17 pr 1 oe oon Hore sch econ # he a msrvideus-fune (u7n) / Premium Table (Baht): tuwus%eU / Annual Term: swumoliifinguoungovied (gui 120 3u domsaerrolakens) Pan & a mac “ew at yr ordi 20 yer te) ame e723 ar ram Te Fraga Wee uwusreirieo / Short Term: Ped of PNA rane oon ma insane ane A 4h a! hoe aq? hoe 15-75 0/ yo 15-7807 yas {70m 8.07 Nesom = 85 yas | ESO 8.07 Nevo 85 ys 207s ‘et Twolie | fale Weaste el Wovens | Aa Wore 13 78 319 72 61 400 or 213 26 4s 14 ss ue et 556 735 209 ui 710 1489 sano 1.081 1320 00 as a2 2396 va 1820 zat 1200 1678 us 1.050 205 sea 1518 aint 2760 1559 197 00 1207 oo 54 saz nat s.109 18 2216 1.004 1381 522 851 va2r 2608 118 205 +202 148 S77 721 2001 2909 2095 2a15, 1.300 1501 on 758 se38 3538 2513 2993 1561 1018 188 as sos, 494 zeae 60 13 2063 as son ‘ox ast 3300 3708 2063 2315 art 18 5350 528 3767 44108 25 2567 a9 1.265 sos 5.904 105 cca 2567 2019 1265 1.980 or73 zz sor 5021 2519 070 1390 is19 720 7319 5020 5409 070 azz 1519 16 ov97 776 543 5057 ave as74 146 a3 masa nae sa58 775 as74 21s ima 11800 e101 ant sz sez 25 “07 4.900 2007 ‘0208 9.508 5001 70 4077 4320 2007 2sa soos 10306 10708 7308 7528 4320 4581 2184 2200 re | t0709 1300 7827 7945 4561 4g32 2200 2408 vase | 11300 11000 7944 9.003 since 5.004 2400 2504 sso1a5 | ta0e 12405 Base ‘722 5084 5336 25a 2661 sara | tans 13002 8781 9309 5206 5587 2661 2768 vaso | 13.09 13000 9198, aor 5507 500 2708 os asiasr | 13600 14206 9616 1.034 5600 om 2a15 oe ssesc | taz06 14903 | 10008 104s2 oot 6309 042 169 65-171, 1408 15481 14st soso o30 504 169 285 ware | t5a81 16078 | 10880 var 6508 5846 3205 aaa w7os00 | 16078 teers | 11.266 11706 6545 7.098 sana ast9 rare / Rar eset he: in, en, ry Kr, ame eK Rope of, 0 Pa Oe ape a ae Wg cot Sau Una Ton Pen tO. Vn «talento? oon Usrediirdalsmadataisnefuninar” Widnes Wri! be acter med ek Ge cox { “GasnimerAscartenrredets Te nm pron ce sa : TuriwataUs:=riusta / Application Form Us:fluriemstdunwerwus:tnA / Travel Guard International Mouonis as rey Mens eed — ou ae u. e a spe ptr gy ae rwansiea | mreanrimnin auygyoen oof LL! Lif Brae] fle os feeresunalind romana rsamelisap tui Merriesssu (iosurec's Estat) TUsrs:yinSoonune nihuwurjunsooririvuian / Insurance Plan selected (Please indicate by check V) “S700 / ANNUAL Dana rene Dre strlen / SHORT TERM: 6 ASIA Gran rms Drnc Drm ‘» WORLDWIDE Tip Pane Dane Pad sconmrlennohat un orey ———— #, ee LLL] seat LLL ‘leo0u. = oO cores ft peau (ey 2 anuSunsusssingunsandayaiwurdiudauary / For group policy, please fill in information belows 1. aime bo rune duveyoiinnn) 2 Anh to vue auevorninny Te en name Se Snes Brns) TT Ghen time Sore Sees Sem) C_] It ] it J ] usireantinooy dass FvoNserad none usoniouonstraa0 1 Oras Felsen iB tpe Clmaissvarewms Gonna 0 ID Blursisgwanirams cost 0 ‘avs Bruralosn Passpon ° Banaucsn Passat 1D Number [____) i 2. rrminto to urvane ‘auveuninn) 4. minha to od ausounranny fare Goon tame Sian SaeetBeN(AS) “Te Gen ne date 0 Bema) Userosninetiooe CB inaledvodsirs ls Ubntoninatoo0 B trelsalsoras lil Sipe Einaspvarswns conn © OT Siursiegvantums Coster 0 crs Sinalsen % Bunalsen oo iS timber Banter 5 fadmrto bo crwane Suvouniiann) 6. mvwarso to una avayarninny Te Sten None Shae Snes BrNAG) Te Gren tne ‘Sore date Bem A) Cot Il 1 Cl ] ] ] userenrNoD Uns Re leas Urano. 1D wrasse ls 1D ony Cliissvarewns comme ID hee BS Ursisgatses Gost 10 ‘ida Einar oo tes Buraen iB tmbec habe 2. uit Bo rena Auvouornoian) 8 fuiwuno Go vuana Suvfouoneian The hen Nae Sam daw Brn(ao) Tee Gren Name Suma ae of rn XO) Coe [ It ] i It ] sannaowunsts obo (DOnsis-dwUsw lors © Usernoooons snob (Grol vous wu fara 0 ope Donsisdwdewms corrnment 10 1D pe ED OnsissvedIs10Ms Goremmen 1D ins Guraiosn Passoor eros runalasn Passpot IB number ID Number 9. uhm bo vruana suveyOinine) Sten Sven Name Samate Bate of Bh 40} Usamnuoudnsrs ve (O Onsisivous Nx D 10 pe Dunas wodwowMs Gorenrent 1D taut Buralbsn Paspor IO hme ‘oppose at TCL te a Bun oe monssraaieamecannicrass cates ciao an wat ib eked fen mane SReee eee ee tne ES ee a eerie CEREEEE To cteearemasetor onset no arnsusrmini / Stat Only [Dy ro ee [Dy eres tate bom [Dy enait soet 0 ne Touran ses siiaomu (rate Ox) au / Ema Instat wir Raenteomy —( ie) ole Intonownensarrahiiaaavatreinihals es Se Rrra Otero sac Carman. 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