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~~~~~~~~~~~ Inbound Travel Insurance Application Form ~~~~~~~~~~~
This insurance is underwritten by: Blue Cross (Asia-Pacific) Insurance Limited
Please print out this form, fill in the required details, then fax to 852-25197296 Tiglion Travel Services Co. Ltd.

Agent Code: 95903303

Applicant This form must be filled in English.
* Fields must be filled in.
Name *

  Title
(eg Mr)

Last/Family *
( eg Wong ) 		First/Given *
( eg David )
Company Name Phone # *
E-mail Address * Fax #
Commencement Date *   (MM / DD / YYYY) For Days
Correspondence Address *


Insured Persons Details  
Title (eg Mr) Name Age * Passport No.*
1. Last * First *
2. Last * First *
3. Last * First *
4. Last * First *
5. Last * First *
　
Declaration
The applicant warrants that to the best of his/her knowledge and belief no insured person is travelling contrary to the advice of a medical practitioner or for the purpose of obtaining medical treatment and that he/she understands that treatment of any pre-existing, existing, recurring or congenital medical conditions is not insured.

Personal Information Collection Statement
I/We understand and agree that any personal information collected or held by Blue Cross (Asia-Pacific) Insurance Limited ("the Company") may be used, stored, disclosed and transferred (within or outside of Hong Kong) to such individuals/organizations associated with the Company or any selected third party for the purposes of processing this application and providing subsequent services for this, and promotion of financial products or services by the Company and its affiliated companies, and communicating with me/us for such purpose. I/We the right to obtain access to and to request correction of any personal information held by the Company. Such request could be made to Company's Corporate Data Protection Officer at 29/F, BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon, Hong Kong .




____________________________




____________________________

Applicant's Signature

Date

All insurance transactions must be arranged within the territory of the Hong Kong Special Administrative Region.

Tiglion Travel Services Company Limited (Lic 350005) and (Insurance Agent Reg 95903303)
[ Insurance Agent for Blue Cross (Asia-Pacific) Insurance Limited & American Home Assurance Company ]

Disclaimer
Rm 902 Yue Xiu Building, 160-174 Lockhart Road, Wanchai, Hong Kong
Tel 852-25117189   Fax 852-25197296
Email: travel@tiglion.com Website: http://www.travel.com.hk 
Copyright (c) 1995 - Tiglion Consultancy Company Limited. All rights reserved.