Fillable Printable CHI Travel Insurance Application Form
Fillable Printable CHI Travel Insurance Application Form
CHI Travel Insurance Application Form
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CHI Travel Insurance
Application Form
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Traveller’s details
Children’s details
( ) ( )
/ / / /
Traveller’s contact details
Travel details
INSURED’S SURNAME FIRST NAME TITLE DATE OF BIRTH
INSURED’S SURNAME FIRST NAME TITLE DATE OF BIRTH
INSURED’S SURNAME FIRST NAME TITLE DATE OF BIRTH
INSURED’S SURNAME FIRST NAME TITLE DATE OF BIRTH
INSURED’S SURNAME FIRST NAME TITLE DATE OF BIRTH
INSURED’S SURNAME FIRST NAME TITLE DATE OF BIRTH
RESIDENTIAL ADDRESS SUBURB STATE POSTCODE
EMAIL
PHONE
(
AFTER HOURS
)
PHONE
(
BUSINESS
)
PHONE
(
MOBILE
)
DEPARTURE DATE RETURN DATE / EXPIRY DATE
PERIOD OF TRAVEL
(
DAYS /MONTHS
)
MAJOR DESTINATIONS
Please do not detach. Return the entire brochure to your agent.
If you have insufficient space to complete your answers, please attach a separate sheet.
Cover required
Single Family Duo
Cover Area 1 2 3 4 Australia
Plan selected Cost
PLAN A Comprehensive $
PLAN B Australia Only $
PLAN C Budget $
PLAN D Frequent Traveller $
PLAN E Non Resident $
PLAN F Residents Returning $
Additional costs
You are not automatically covered for Pre-existing Medical Conditions.
Please refer to the definition of and guidelines for Pre-existing Medical
Conditions on pages 9 to 14 of the PDS.
Do you have a Pre-existing Medical Condition (as outlined in the PDS)?
Yes No
Do you want cover for your Pre-existing Medical Condition for your Journey?
Yes No
We are unable to offer cover for those Pre-existing Medical Conditions outlined on pages 10
& 11 under the heading “Group 1 – Pre-existing Medical Conditions which are automatically
excluded”.
If you have any of the conditions which are excluded, travel insurance is still available to
you, however, there is no provision to claim for any of the medical conditions as listed
in Group 1 (pages 10 & 11).
If you do not expressly apply for cover and pay an additional premium for Pre-existing
Medical Conditions, your claim may be declined.
1. Do all your Pre-existing Medical Conditions fall under Group 2?
Yes No
(If yes, we do provide automatic cover for these Pre-existing Medical Conditions
listed in Group 2 at no additional premium)
2. Are you required to complete and submit a Medical Declaration Form?
Yes No
(If yes, please complete the Pre-existing Medical Condition application form.
If your application for cover is approved, an additional premium will be payable.
Only available for Plans A, B & D.)
Travellers 61-80 years additional premiums
$
Travellers 81 years or over additional premiums
$
Approval codes
Pre-existing Medical Conditions additional premiums
$
Approval codes
Increased Rental Vehicle Excess Cover (not available Plan C)
$
Additional Sum Insured $ Additional Premium
Specified Luggage and Personal Effects Cover (not available Plan C)
$
Specified items and value $
Removal of Standard Excess (not available Plan F)
$
TOTAL COST $
Declaration
1. I/we acknowledge that a copy of the combined Financial Services Guide [FSG] and Product
Disclosure Statement (including Policy Wording) [PDS], were provided to me/us before I/we
applied for this insurance, and that I/we have made the decision to purchase the policy after
carefully reading the terms and conditions contained in the PDS, and agree that this product is
suitable for my/our needs.
2. I/we acknowledge that I/we have read and understood the Duty of Disclosure and the
consequences of non-disclosure.
3. I/we authorise any doctor or clinic to provide Allianz Global Assistance with information
concerning my/our current or past medical history. I/we have read the Privacy Notice and I/
we consent to the collection, use and disclosure of my/our personal information by Allianz or
Allianz Global Assistance to such persons and for such purposes stated in the Privacy Notice.
4. I/we acknowledge that this policy does not automatically provide cover for Pre-existing
Medical Conditions.
5. I/we agree to abide with the terms and conditions of this policy and confirm that the above
information is correct.
Insured/Sponsor Signature Date
Insured/Sponsor Signature Date
If Duo has been selected, both insured’s must sign.
