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Age
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Home Address
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Return Date
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Number of Days		 �ѹ / Day
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Name of Beneficiary
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Coverage
Economy
Class		 Premium
Class		 Business
Class		 First
Class
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Premium
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Please provide complete information to process insurance
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Cash Benefit during Hospital Confinement per Day, Max. 20 Days
500
1,000
1,500
2,000
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Medical Expenses Each Injury/Sickness
500,000
1,000,000
1,500,000
2,000,000
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Loss of Life, Dismemberment, Loss of Sight, or Total Permanent Disability, due to Accident (P.A.1)
250,000
500,000
1,000,000
1,000,000
��ú�ԡ����������������������ҧ����Թ�ҧ�� International SOS
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Worldwide Emergency Assistance Service Provided by International SOS
- Emergency Medical Evacuation
- Medical Repatriation
- Repatriation of Mortal Remains
 USD 1,000,000