Step 1 of 3 - Travel Insurance Online Form

Departure Date

Arrival Date

Type of Plan

Insured Types

Trip Type

Zone of Travel

Destination Countries

Age

Hidden

Single Trip Plan/Individual/First

Coverage Period Based On No of Days Travel

Hidden

Single Trip Plan/Individual/Executive

Coverage Period Based On No of Days Travel

Hidden

Single Trip Plan/Family/First

Coverage Period Based On No of Days Travel

Hidden

Single Trip Plan/Family/Executive

Coverage Period Based On No of Days Travel

Hidden

Annual Plan/Individual/First

Age

Hidden

Annual Plan/Individual/Executive

Age

Hidden

Annual Plan/Family/First

Age

Hidden

Annual Plan/Family/Executive

Age

Your Yearly Premium is: (includes SST and stamp)

Policy Wording

Schedule Benefit sheet

Name(Required)

IC Number

Address

Street Address Address Line 2 City State Poscode Country

Phone(Required)

Email(Required)

Nominee Details (Up to 6 Persons)

Name

IC Number

D.O.B

Address

Relationship

% of Share

Family Details

Wife Name

IC Number

Relationship

Children (Up to 9 Persons)

Name

IC Number

Relationship

Nominee Details (Up to 4 Persons)

Name

IC Number

Relationship

% of Share

Payment Method

All Premium Amount included SST 6%. We are now support online payment gateway through SecurePay for better experience. RM1.50 will be charge for every transaction. For Credit Card, you will be charged 0.3% per transaction.

Your Total Premium is:

Credit Card Charged

Price: RM 0.00

Choose Payment Method(Required)

Pay Now (Online Banking)

Pay Now (Credit Card)

Pay Later

Please choose correct payment method to proceed.