Signup Form

Existing Insurance Company and policy type

Given/First Name

Sex

Date of Birth

Passport Number

Phone

Email Address

Residential Address

Country of Origin

Existing Policy information

Coverage Selected:

Plan A (single trip) Plan B (annual)

Premium Type

Individual Couple Family

Period of Membership

Plan A (Single trip)

Plan B (Annual trip)

2nd Member of Same Policy:

Family/Last Name

Given/First Name

Sex

Date of Birth

Passport Number

Phone

Email Address

Residential Address

Country of Origin

Existing Policy information

3rd Member of Same Policy:

Family/Last Name

Given/First Name

Sex

Date of Birth

Passport Number

Phone

Email Address

Residential Address

Country of Origin

Existing Policy information

4th Member of Same Policy:

Family/Last Name

Given/First Name

Sex

Date of Birth

Passport Number

Phone

Email Address

Residential Address

Country of Origin

Existing Policy information

Emergency Contact

Full Name

Phone Number

Relationship

Declaration

I hereby apply for _____________ to be based on the above statements, and warrant that to the best of my knowledge and belief that no Insured Person is traveling contrary to the advise of a medical practitioner or for the purpose of obtaining medical treatment and that I understand treatment of any pre-existing, existing, recurring or congenital medical conditions is not insured. I further warrant that I am not aware of any condition, cause or circumstances that may necessitate the cancellation or curtailment of the journey as planned.

Referral

Note: No refund of premium will be made once the membership has been purchased.
Address: Eastern Harbour Centre, 28 Hoi Chak Street, Quarry Bay, Hong Kong
Tel: +852 52169996
Email: info@asapmission.com