TRAVEL INSURANCE APPLICATION FORM
First Name: Family Name:
Date of Birth*: Place of Birth:
Address: Phone:
Citizenship: Passport Number:
Departure Date: Return Date:
Destination: Address at Destination:
Phone at Destination: Other Destination(s):
Air Line
Trip Type (Business/Holiday/etc): TIN Number
EMAIL ADDRESS:
Next of Kin: Relationship:
Address (For Next of Kin): Tel:
Other persons to be insured with their details
Name Occupation Passport Number Date of Birth Relationship with the Proposer
PTO PTO
Does any proposed insured suffer from physical defects or infirmities? YES/NO. If Yes, please give particulars
Are all proposed insured now in good health? YES/NO. If No, please give particulars:
Is any of the proposed insured travelling for the purpose of receiving medical treatment? YES/NO. If yes, please give particulars:
Has any proposed insured been treated for or told they had diabetes, abnormal blood pressure, any disorder or disease of the heart, lung back or spine, a mental, nervous
or weight condition, cancer, kidney or liver disease, alcoholism or drug addiction of any other disease? YES/NO. If yes, please give particulars:
Has any proposed insured had any personal accident, sickness, baggage or travel insurance cancelled or declined or renewal refused? YES/NO. If yes, please give
Is any proposed insured already a member of any medical/rescue insurance scheme? YES/NO. If Yes, Please give particulars
Has any proposed insured ever made a claim in respect of loss of baggage? YES/NO. If Yes, please give particulars:
I warrant that the above statements are true, and that I have not withheld or concealed anything affecting the proposed insurance, and I agreed that this proposal and
declaration shall be the basis of the contract between me and the underwriters. I hereby consent to CIC General Insurance Uganda Ltd contacting my doctor or medical
institution to obtain medical information about me and hereby authorise such doctor or institution to make full disclosure of such information to CIC General Insurance
Uganda Ltd or its advisers, and to provide access to my complete medical and hospital records in order to proceed with assessment of a claim and/ or render medical
assistance. I agree also to accept the underwriter’s policy applicable to the insurance.
Date: Signature:
PTO PTO
