Traveleasy Acceptance Form

Important Notes:

•	All material facts must be disclosed.  Failure to do so may invalidate this policy.  A material fact is one which is likely to influence an insurer in the assessment and acceptance of the proposal.  If you are in any doubt as to whether a fact is material, it should be disclosed to the insurer.

•	We reserve the right to ask for special term or decline this proposal.

•	No Cover for Iran, Iraq and Palestine
_____________________________________________________________________________
I wish to apply for Traveleasy travel insurance for myself/members of my family/party detailed below.

1. Name: Mr/Mrs/Ms___________________________________________________
 
2. Date of birth & Age	: ______________________________________________

2. Address	: P.O.Box: ________________ , Area:  ___________________________
		   
Tel. no.	:______________________e-mail: ______________________________

3.Name of others to be insured

(a) _______________________________ Date of birth: ______________
(b) _______________________________ Date of birth: ______________
(c) _______________________________ Date of birth: ______________
(d) _______________________________ Date of birth: ______________
(e) _______________________________ Date of birth: ______________

4.Beneficiary Name, Address & Contact No.: 

________________________________________________________________________

5. 	In case of Single trip cover
Start date of  Trip                 	: ______________________________ 
No. of days cover required		: ______________________________
    	Return date				: ______________________________

In case of Annual Policy
Period of Cover			: From	____________To___________	

6. Countries to be visited: (Applicable only for Single Trip cover)
1)	2)	3)	4)	

7. Please answer the questions below as fully as possible:
If the answer to any of the questions is yes then give the details in the space provided.

(i) Will either you or any person be participating in any sport or hazardous recreation.

Yes  	 No 

If yes, give details …………………………………………………

(ii) Are you or any person to be insured suffering from any medical condition or illness or have you are any person to be insured had any medical treatment in the past 2 years. If so please give details 

Yes 	 No     

(iii) Are you aware of any situation which might delay or cancel your trip? If so give details

I hereby declare that the above details are true to the best if may knowledge.

Date  _________________		Signature of Proposer _____________________

Policy Delivery (Please tick the appropriate option)

1.	Please courier the Policy to the address mentioned above	(  )
2.	I would collect the Policy in person				(  )

Method of Payment : 					   

	Cash / ATM Electron cards / Cheque payable to the Oman Insurance Co. P.S.C. enclosed

   	Please debit my/our credit card account with the total amount shown below for the purchase/Renewal of  Travel Insurance 

Please note that the below mentioned is to be filled only incase of Non Electron Cards

Amount:  
(In words)
______________________________________________________DHS: 

	VISA			MASTER CARD	       Expiry date: ______________

Card Holder’s Name ________________________________Signature____________

Address: _______________________________________________________________	

Insurance Period	Producer
(Full name)	Mode Of Payment
(Tick appropriate)	Delivery Option	
From	To		Cash	Credit	Debit Account	Cheque	o	In Person
o	Courier
o	Fax
o	Email
o	Others
       (Specify)	

Official Use
Remarks:

Certificate issued by: __________________________________________________________

Date: ____________________________  Signature:  _________________________________