TRAVEL INSURANCE APPLIC ATION FORM LEISURE AND BUSINESS Olga Mahlare

Please indicate with a cross: Type of Cover: Individual Family Group Product: Platinum Gold Inbound Frequent Flyer: Yes No Senior Student/Youth Silver Other

Please Note: There is no pre-existing cover offered on the Platinum and Business Frequent Flyer options.

Insured Person(s) Surname

Initials

Date of birth Beneficiar ID/Passport Number

Date of Departure

Date of Return

Total Premium

1. 2 3. 4.

R R R R

Please note that rates are subject to change. Please contact the call centre for details on the most up to date premiums.

Postal Address:

Tel (C): (

Tel (W) :(

E-Mail Address: Has the public conveyance ticket been paid for with a valid South African Credit Card? Yes Total Number of days (departure and return date inclusive): Furthest Destination: No

Credit Card / Cheque Card Payment: Card Type: Card Holders Name: Card Number: Expiry Date: CVV Number: You will be contacted by one of our consultants to confirm your CVV Master Visa

Chartis South Africa is an authorised Financial Services Provider. Chartis South Africa VAT Number: 4390116939

FINANCIAL NEEDS ANALYSIS (Please indicate with a cross) Please answer the following questions: Do you currently have a similar product? Are you comfortable that you understand our insurance product and that it satisfies your insurance needs? Do you understand and accept the cost associated with this product? Yes No

PLEASE NOTE THAT OUR TRADING HOURS ARE AS FOLLOW S: Monday Tuesday W ednesday Thursday Friday Saturday Sunday Public Holidays 8:00 AM 06:00 PM 8:00 AM 06:00 PM 8:00 AM 06:00 PM 8:00 AM 06:00 PM 8:00 AM 05:00 PM 8:00 AM 01:00 PM CLOSED CLOSED

TRAVEL AGENT USE ONLY: Travel Guard Internet User ID: AIG Internet Password: Agency Name: E-mail Address:

PLEASE SIGN BELOW : I hereby authorise Chartis South Africa Limited to debit my Credit card / cheque card account for the selected optional travel insurance per person, per journey. I/we understand that this is subject to the Terms and Conditions, Exclusions, Rates and Exceptions of the master policy, which may be reviewed and updated from time to time. Should I not receive my policy wording within 48hours, it is my responsibility to contact Chartis South Africa Limited on the details below and inform them of this. My application or query will only be acknowledged during working hours as mentioned above and cannot be captured or assisted if received after the stipulated working hours. If any information is received after working hours this will only be examined on the nex scheduled operational period. The policy is available from Chartis South Africa Limited on Tel: 0860 100 491. Signature: Date:

Remember to return this application immediately after completion in order to activate your cover.

Fax to: Travel Guard 086 625 4818 or Email to: sacallcentre@za.aegisglobal.com

Chartis South Africa is an authorised Financial Services Provider. Chartis South Africa VAT Number: 4390116939