Ntu Travelsure Application Form

NTU TRAVELSURE APPLICATION FORM

Statement pursuant to Section 25(5) of the Insurance Act, you are to disclose in the Application Form, fully and faithfully, all the facts that you know or ought to know, otherwise this Policy issued hereunder may be void.

Eligibility of Cover

· Insured must be a Student or Staff from an NTU College/School/Department/Research Centre

· Insured must be domiciled in Singapore

· The trip must start and end in Singapore within the period of Insurance

Please complete all fields and payment instructions before submission. Only students are required to fill in their matriculation number. You will receive an acknowledgement via your email. Your Travel Insurance Certificate and Policy will be issued within 5 working days and they will be sent to the registered email address. No hard copies will be sent.

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INSURED PARTICULARS:

Staff or

Student Matriculation No: School/Department:

Name: Nationality: Singapore Singapore PR Others

Mobile Phone No: Email Address:

NRIC/FIN No: Date of Birth: (dd/mm/yyyy) Sex: Male Female

Mailing Address: Postal Code:

Travel Plan: Standard Standard Plus

Geographical Area: ASEAN ASIA WORLDWIDE

Number of Days: (Inclusive of arrival date in Singapore)

Period of Travel: From: (dd/mm/yyyy) To: (dd/mm/yyyy)

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PAYMENT DETAILS

Cheque Payment

Cheque No: Amount: $ Bank:

Credit Card Payment

Amount to be deducted: $ Card: VISA MASTERCARD AMEX

Name on Credit Card: (Cardholder must be the Policy Holder, Spouse, Parent or Sibling)

Card No: Expiry Date: (mm/yyyy) CVV No:

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This policy is subject to Payment Before Cover Warranty, ie, full premium payment must be made before inception at the time of documentation. No refund of premium is allowed for the Single Trip Plan once the Certificate of Insurance and/or Policy is issued.

CONDITIONS

· Pre-existing medical conditions are not covered by the Policy.

· The trip must not be for the purpose of seeking medical attention.

· The Insured person must be domiciled in Singapore.

DECLARATION
I hereby declare that I am in good health and am aware of and agree to abide by the Policy’s Terms, Conditions and Exclusions. I also understand that the issuance of the policy is based on all statements and answers set out in this Application Form which are complete and true. I am aware that I can seek advice from a qualified adviser before making a commitment to purchase the product. In the event that I choose not to seek advice from a qualified adviser, I take sole responsibility to ensure that this product is appropriate for financial needs and insurance objectives.

Please mail your completed Postal Application Form and payment to:

Admin (NTU TravelSure) 31B Lowland Road Singapore 547425