1
Travel Insurance Plan Information
Covid Upgrade 50K
1
(Age 18 to 75)
0
(Age 76 to 80)
0
(Age 81 to 85)
PaxCount = 1 AdultCount = 1 ChildCount = 0
PaxNormal = 1Pax76 = 0 Pax81 = 0
Normal = 1 76-80 = 0 81to85 = 0 Child Range = 0
Total:
1 Day
Essential
Extra
Coverage
Sum Insured (PHP)
Covid Upgrade 50K
Single
1
1
PHP 0.00
Covid Upgrade 50K
*Denotes items for mandatory completion
1. The applicant must be 18 years old
1
Fill in individual information
2. Premium loading is applicable for an insured person or traveler who is above 75 years old on all Short-Term Travel Plans
Applicant Detail
*
*
*
*
*
*
*
Insured Person Information
1st Insured Person is Applicant 
Normal = 1 76-80 = 0 81to85 = 0 Child Range = 0
1---0---0---0
0===0
0&&0&&0&&0
*Relationship To Applicant
*Name
*Passport/ID No
*Birthdate
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Emergency Contact Details
*
*
*
AMLA Information
*
*
*
Declaration
The producer hereby warrants and declares on behalf of the Propose Insured and/or all members of the travelling party (collectively "Proposed Insured") as follows:
I/We declare to the best of my/our knowledge and belief that the information given is true in every respect. I/We agree that this application and declaration shall form the basis of the contract between me/us, tripmoba.com and 3rd party provider of about to be purchased travel product/services. I/We authorize a 3rd party provider through  tripmoba.com to obtain medical information from my/our medical practitioner(s) and I/we agree to supply additional information relevant to this insurance policy at my/our own expense. The insurance policy will be in force upon acceptance by tripmoba.com with a 3rd party provider. I/We hereby declare, agree and consent that any personal data collected or held by tripmoba.com (whether contained in this application or otherwise obtained) is provided and may be held by, used by and disclosed by tripmoba.com to a 3rd party provider and its subsidiaries, related companies, group companies, and/or any individual/organization associated with its company such as product distributors, contractors, other financial service providers or persons or entities providing administrative, operational, customer, technical and/or telecommunication support to tripmoba.com and 3rd party provider and/or its companies, within or outside the Philippines, for the purposes of processing this application and/or providing subsequent insurance-related services, including but not limited to administering the policies issued to you and/or processing any claim under the policies issued to you. I/We understand that tripmoba.com and 3rd party provider may be unable to process this application if I/we fail to provide any information requested in this application, and I/we have to right to request not to receive any direct marketing materials or calls, or to request access to and/or correct any personal information held by tripmoba.com and 3rd party provider concerning me/us. Such request can be made to tripmoba.com's and 3rd party provider's Data Privacy.
Policy Terms and Conditions
*I/We have read, understood and accepted the above statements, policy terms and conditions, including exclusions and limitations, which apply to all persons covered under this policy. I/We understand that upon my/our enrollment being approved by tripmoba.com and the 3rd party provider, the premium under my/our policy will be paid in cash or will be debited from the given Credit Card Account.
I/We agree and consent to my/our name(s), address(es), telephone number(s) and email address(es) being used by tripmoba.com and a 3rd party provider and/or provided by tripmoba.com and the  3rd party provider to tripmoba.com and the  3rd party provider companies and/or other selected third parties for direct marketing and the promotion of other insurance/financial products and services.
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