Accident & Health
Department
21st-23rd Floor, Siam Tower , 989 Rama I Road, Patumwan, Bangkok 10330, Thailand
Tel: 0-2649-1000
PA Plus Application
I would like to choose
Personal Plus
Family Plus
Plan 1
Plan 2
for Executive Plus Plan
with Medical Reimbursement
Plan 3
Senior Plus
Executive Plus
Plan 4
Non – Medical Reimbursement
Inception Date ……………………………… Expiry Date ……….…………………… 12.00 a.m.
Insured Name (Mr. / Mrs./ Ms.) ………………………..…………. Last Name …………………………………………………..
Date of Birth ……………………….…………….. Age ……………….. Years
Address ……………………….…………………………………………………………………………………….……….………...
………………………………………………… Tel ……………………………….. Mobile ……………………….……………….
ID Card / Passport No. ……………………….……………. Issue by …..………….……….. Province…...…………….………
Occupation ……………………………………….………… Position ………………….…………………………………………...
Annual Income ………………………………….………………………………….………………………………………………….
Company Name …………………………………………….. Address …………….………………………………………………
………………………………………………………………….…………… Tel ………………………………………….…………
Beneficiary ………………………………………..…………….……………… Relationship ……….……………………………
Tel ………………………………………...……..……………….. Mobile …….…...……………………..………………………..
Beneficiary (2) …………………………..………..…………….……………… Relationship ……….……………………………
Tel ………………………………………………..……………….. Mobile …….…...……………………..………………………..
for Family Plus Plan
Spouse Name ………………………………….………..……..….. Date of Birth ………………….. Age ………………………
Beneficiary ……………………………………………….….…….. Relationship …………………………………………………
Child Name (1) …………………...…………………….....…….. Date of Birth ………………….. Age ………………………
Beneficiary ………………………………………….…….....…….. Relationship …………………………………………………
Child Name (2) …………………...…………….…….…...…….. Date of Birth ………………….. Age ………………………
Beneficiary …………………………………………..…………….. Relationship …………………………………………………
Do you have any Personal Accident Insurance Policy or Life Insurance Policy with any Insurance Company?
No
Yes (Please specific ……………………………………..)
Do you have good health and good physical condition?
Yes
No (Please specific ………………………………………)
Do you ride motorcycle or any similar vehicle?
Yes
No
Do you have any specific disease as follows: Diabetic, Heart Disease, Hypertension, Cancer or others?
No
Yes (Please specific ……………………………………..)
I/We warrant that the above statements are true and correct and agree that this proposal shall be the basis of the
contract between me/us and the Company.
………………………..
…..……………………..
Written by
Proposor’s Signature
Date ………………..
Agent
Broker………Mr.Surachai Siriphat 024301/CB………www.aiapattaya.com.
Telephone……085-121 3232 ……Email:insurance@aiapattaya.com …….