Student Corporate Individual Student Insured Name **Name is missing Phone no. **Phone is missing Geographical Coverage Including USA/Canada Rest of world Date of Birth **Select Date Days of Travel 0 to 30 31 to 60 61 to 90 91 to 120 121 to 180 181 to 270 271 to 365 **Select Trip Band Coverage amount $ 50,000 $ 1,00,000 $ 2,50,000 $ 5,00,000 **Select Sum Insured COVID cover mandatory? Yes No Do you suffer from any pre-existing medical condition? Yes No Total Premium
