You are on page 1of 2

Chartis is one of the world’s leading property-casualty and general insurance organizations.

Serving more than 45 million commercial and personal clients in more than 160 countries and jurisdictions, Chartis has a 90-year history, one of the industry’s most extensive ranges of products and services, and excellent strength. Chartis enables its commercial and personal insurance clients alike to manage virtually any risk with Chartis is the marketing name for the worldwide propertycasualty and general insurance operations of Chartis Inc.
Producer Stamp

This brochure is not a contract of insurance. The terms, conditions and exclusions applicable to this insurance are set out in the Policy, a copy of which is available upon request. TGC/SBE/0410A

Stu de

nt A

ssis

t

Chartis Singapore Insurance Pte. Ltd.
CHARTIS Building 78 Shenton Way #07-16 Singapore 079120

Tel : 65 6419 3000 Web: www.chartisinsurance.com.sg Co. Reg. No. 201009404M This insurance is underwritten by Chartis Singapore Insurance Pte. Ltd. Copyright in this Policy is reserved. No part of this Policy may be reproduced in whole or part without the express consent of Chartis Singapore Insurance Pte. Ltd.

damage or legal liability arising directly or indirectly from travel in. 142) (Amendment of First Schedule) Order 2010”. payment received in full and a Policy is issued.14 Premium I/We agree that any information collected or held by Chartis (whether contained in the Application or otherwise obtained) may be used and disclosed by Chartis to its associated individuals/companies or any independent third parties (within or outside Singapore) for any matters relating to this application. Ltd. Sudan or Syria.88 2. the contents of the brochure and any information material relating to this insurance product.Study with complete peace of mind .40 1. will not cover any loss. Pre-existing medical conditions are not covered by the policy. Child or Children shall mean a person below 18 years of age and must not be employed during the Policy period) Warranty and Declaration: The Insured Person(s) hereby warrant and declare for themselves and on behalf of all members of the travelling party as follows: (I) I/We hereby declare that I/We have received. Iraq.20 Statement pursuant to the Insurance Act or any amendments thereof: You are to disclose in this Form. Credit Card Payment Card Expiry Date: M M Y Y MasterCard Card Account No: Visa AMEX Diners NB: Policy will be issued upon receipt of approval from the respective credit card company.10 1. 4.134. (VI) I/We agree and authorise any medical source (including hospitals and clinics).694.: Address: Postal Code: Tel: Email: Country: Name of Institution: (H) (O) (HP) Date of Birth: Effective Date: (DD/MM/YY) Mode of Payment (Please tick accordingly) Cash Payment Cheque Payment This will serve as an Bank Cheque No.319. Spouse (Applicable for Family Plan) Name: Passport/NRIC No.35 572. insurance or any other organisation to release to the Company at any time any information concerning the Insured Person(s) if required. fully and faithfully. any policy issued and to provide advice or information concerning products and services which Chartis believes may be of interest to me/us and to communicate with me/us for any purpose.259.495.70 Premium Important Notice: 1.24 Core + Plan C 2. conditions and exclusions. (V) I/We are currently in good health. declarations and disclosures therein and herein shall form the basis of the policy. (IV) I/We are not travelling contrary to the advice of a Medical Practitioner or for the purpose of obtaining medical treatment. Iran. Family Duration Core Plan 6 months (182 days) 1 Year (Inclusive of 7% GST) Type of Plan Core + Plan A 953. I hereby declare that I am ordinarily resident in Singapore as by “Insurance Act (Cap.508. Liberia. 3. Cuba. free from all physical impairment and deformity. (III) I/We are aware of and agree to abide by the Policy’s terms. Neither the brochure nor the Application Form is a contract of insurance.39 Core + Plan B 1. Democratic Republic of Congo. 321. your warranties. 706.189.: Relationship to Student: Choice of Plan (S$) (Please tick accordingly) Individual Duration Core Plan 6 months (182 days) 1 Year (Inclusive of 7% GST) Type of Plan Core + Plan A 433.: Relationship to Student: Number of Accompanying Child(ren): (For Family Plan.45 Core + Plan B 770.37 1. However. receipt once cheque clears. the policy issued may be void and you may receive nothing from the policy.20 847. Signature of Insured Person or His/Her Authorised Representative Producer Name: Producer Code: Date . or have been advised of and understand. injury.Apply Now Student Assist APPLICATION FORM The Student Name: Passport/NRIC No. or through Afghanistan. read and understood. conditions and exclusions applicable to the insurance are set out in the policy. The terms.44 Signature of Parent/Guardian Date Country Exclusion Chartis Singapore Insurance Pte. Name: Date of Birth: Passport/NRIC No.: Date of Birth: Parent/Guardian (for students below 16 years old) Name: (Mr/Ms/Mrs/Dr) Passport/NRIC No. otherwise.22 3. to.00 385.20 Core + Plan C 995. 2. all the facts that you know or ought to know. (II) I/We understand and agree that no insurance is in force until an Application is accepted by the Company.