Annexure - A

Product Details
Worlwide Excluding USA, Canada, Australia & Japan
Worlwide Including USA, Beneficiary Details:
Product Plan Beneficiary Name:
Basic Standard Gold Platinum Relationship:
$15,000 $35,000 $70,000 $100,000 Address

COVID 19
CNIC Number (Beneficiary):
CNIC Issue Date

Coverage
Individual Family
Family Details: (If Traveling)
Number of Family Members Travelling:
Travel Details Name of Spouse:
Country of Visit: Date of Birth (Day/Month/Year):
Period of Journey: From: To: Passport No.(Spouse):
Total Number of Days:
Name of Child (1):
Personal Details: Date of Birth (Day/Month/Year):
First Name: Last Name: Passport No.:

Date of Birth (Day/ Month/ Year): Name of Children (2):

Passport Number: Date of Birth (Day/Month/Year)
CNIC Number (Self): Passport No.:
CNIC Issue Date
Occupation: Name of Children (3):
Address ((Home/Office): Date of Birth (Day/Month/Year):
Passport No.:

Province: City: Name of Children (4):

*Mobile No Date of Birth (Day/Month/Year):
*Email Address: Passport No.:

CNIC Issue Date

Declaration: I/ We hereby declare the beneficiary (ies) of the travel certificate, that all declarations are true and after reviewing the conditions I agree and confirm its contents.
Furthermore, I confirm my (our) declaration that all preexisting cases are not covered by this certificate and coverage is valid only outside my (our) country of residence and
my (our) certificate is not by any mean an authorization to seek treatment abroad. I (we) agree that this certificate cannot be cancelled or amended after its inception.

Note:
Copy of CNIC must be sumbitted along with this application form
The fields mark in asterik are mandatory Applicant's Signature