Travel PA Application Form

Name as in IC or Passport:

* Required fields

Title:

Gender:

Marital status:

Date of Birth

Day Month Year *

IC No/Passport :

Residence Address:

* Postcode: *

Occupation:

Contact tel. number:

Email address:

Beneficiary name:

Beneficiary IC/Passport No:

Relationship:

Benefit Percent (%):

Beneficary Date of Birth:

Day Month Year *

If more than one Beneficiary, pl. type here:

Type of coverage:

Leaving Malaysia:

Day Month Year *

Returning to Malaysia:

Day Month Year *

No. of days of cover:

Region selected:

Any comment?

Region 1:	Malaysia (East to West Malaysia or vice versa), Singapore, Indonesia, Thailand, Brunei, Vietnam, Philippines, Myanmar, Cambodia, Laos, China, India, Korea, Pakistan, Sri Lanka, Taiwan, Hong Kong and Macau.
*Region 2:*	Worldwide excluding USA / Canada (E.g. New Zealand, Australia)
Region 3:	Worldwide including USA / Canada.

Please submit this form at least 1 week prior to departure. Thanks and have a great day!

If you have any query, please use our Enquiry form, E-mail us or call Mr. Jimmy Tan 012-5158027