TRAVEL INSURANCE ONLINE FORM

Step 1 of 3 - Travel Insurance Online Form

Departure Date
DD slash MM slash YYYY
Arrival Date
DD slash MM slash YYYY
Type of Plan
Insured Types
Trip Type
Zone of Travel
Destination Countries
Destination Countries
Destination Countries
Age
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Single Trip Plan/Individual/First
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
This field is hidden when viewing the form
Single Trip Plan/Individual/Executive
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
This field is hidden when viewing the form
Single Trip Plan/Family/First
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
This field is hidden when viewing the form
Single Trip Plan/Family/Executive
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
Coverage Period Based On No of Days Travel
This field is hidden when viewing the form
Annual Plan/Individual/First
Age
Age
Age
This field is hidden when viewing the form
Annual Plan/Individual/Executive
Age
Age
Age
This field is hidden when viewing the form
Annual Plan/Family/First
Age
Age
Age
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Annual Plan/Family/Executive
Age
Age
Age
Your Yearly Premium is: (includes SST and stamp)
The benefit(s) payable under eligible certificate/policy/product is(are) protected by PIDM up to limits. Please refer to PIDM's TIPS brochure or contact Chubb Insurance Malaysia Berhad or PIDM (visit: www.pidm.gov.my).
For detailed information, kindly download below:

Policy Wording

Product Disclosure sheet

Schedule Benefit sheet

Name(Required)
First
IC Number
Phone(Required)
Email(Required)
Address
Street Address Address Line 2 City State Poscode Country
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