Travel Insurance Application Form

Please complete this form in English or Chinese and check where appropriate.

(I) Details of Applicant

Correspondence Address in Hong Kong

Contact Telephone No.

(II) Product Particulars

(III) Details of Insured Person(s)

Surname Given Name Gender Date of
HKID Card/
Passport No.
Place of Origin Action

(IV) Opt-out from Use of Personal Data in Direct Marketing

Asia Cosmos Wealth Management Group Ltd (the "Company") may use your personal data for direct marketing but the Company cannot use your personal data for such purpose without your consent. Please check in the box below if you do not wish the Company to use your personal data for direct marketing.