TBF NO.

INVOICE NO.

RECEIPT NO.

REF. NO.

CHOICE OF PLAN: INDIVIDUAL FAMILY INSURED & SPOUSE

AREA: REGION 1 REGION 2 REGION 3

CHOICE OF BENEFIT: SUPERIOR PREMIER

DESTINATION: PER TRIP ANNUAL

# NAME OF INSURED PERSON IC NO. (NEW) D.O.B** MARITAL STATUS

1

2

3

4

ADDRESS DURATION OF INSURANCE:

FROM: TO:

POSKOD: PREMIUM AMOUNT: RM______________

TEL: EMAIL:

BENEFICIARY:

NAME NRIC NO. RELATION PERCENT D.O.B**

** D.O.B means 'Date of Birth'

ATTEND BY: DATE OF ISSUE:

(STAFF'S NAME)

AIG TRAVEL ASSIST PROPOSAL FORM(PLEASE WRITE CLEARLY)