44/1 อ.รุ่งโรจน์ธนกุล ชั้น 12 ถ.รัชดาภิเษก แขวงห้วยขวาง เขตห้วยขวาง กรุงเทพมหานคร 10310 Tel: +66 (0) 2202 9500 Fax: +66 (0) 2202 9555
44/1 12 Flr, Rungrojthanakul Bldg., Ratchadaphisek Rd., Huay Khwang, Bangkok 10310 Tel: +66 (0) 2202 9500 Fax: +66 (0) 2202 9555
ทะเบียนเลขที่ 0107555000597
เลขประจำตัวผู้เสียภาษี 0107555000597
POLICY SCHEDULE
Accident and Coronavirus Disease 2019 (COVID-19) Insurance (Sell through online channel)
Company code : SCI
Policy No. : PSC-22-ACOB-140707
1. Insured Name :
MRS.TRY SAMNEANG
Address : Sophal Thavy Guest House Poipet Banteay Meanchey, cambodia, 010407
Gender : Female
Birth date :
2. Benefitciary Name : MRS.TRY SAMNEANG
1 February 1977
Occupation : Relationship with insured :
Legal heir
Address :
3. Insurance period : Start date
28 May 2022
at 00.01 am.
To
27 June 2022
At 24.00 am
4. Limited amount of liability: This insurance policy provides coverage only for the items for which the benefit amount is stated.
Insuring Agreement/Endorsement
Sum insured (Baht)
- Benefit of the Corona virus for the Coma
- Benefit of the Medical Expenses for the Corona Virus
- Benefit from vaccine Corona virus side effect for the Coma
- Funeral Expenes in case of loss of life from injury or illness
700,000
700,000
30,000
1,000
Net Premium
Stamp duty
VAT
Total Premium
Direct
Contract Date
Agent
28 May 2022
Premium (Baht)
Included
604.48
3.00
42.52
650.00
X Broker TQM INSURANCE BROKER CO.,LTD.
License No. ว00019/2546
Issue Date
28 May 2022
as evidence the company where the authorized person has signed and affixed the company's seal mainly at the company's office
------------------------------------Director
------------------------------------Director
------------------------------------Attorney
44/1 อ.รุ่งโรจน์ธนกุล ชั้น 12 ถ.รัชดาภิเษก แขวงห้วยขวาง เขตห้วยขวาง กรุงเทพมหานคร 10310 Tel: +66 (0) 2202 9500 Fax: +66 (0) 2202 9555
44/1 12 Flr, Rungrojthanakul Bldg., Ratchadaphisek Rd., Huay Khwang, Bangkok 10310 Tel: +66 (0) 2202 9500 Fax: +66 (0) 2202 9555
ทะเบียนเลขที่ 0107555000597
เลขประจำตัวผู้เสียภาษี 0107555000597
To whom it may concern,
FWD COVID Inbound Certificate
This is to certify that MRS.TRY SAMNEANG
Passport No. N01916768
is covered for inpatient medical expenses from sickness and accident including any sickness caused by COVID-19 (1)
while travelling in Thailand underFWD Covid Inbound Insurance. Policy No.
PSC-22-ACOB-140707
- Covid Inbound Insurance Policy plan starting from 28 May 2022
to 27 June 2022
with
benefits as below:
No.
Benefits
Baht
1
Benefit of the Corona virus for the Coma
700,000
2
Benefit of the Medical Expenses for the Corona Virus
700,000
3
Benefit from vaccine Corona virus side effect for the Coma
30,000
4
Funeral Expenses in case of loss of life from injury or illness
1,000
*The coverage meets the minimum requirement of 20,000USD for Certificate of Entry (COE) Application
Please refer to the Insurance Policy for full detail of insurance conditions, coverages and exclusions.
Remark:
1. Definition of COVID-19 follows criteria from the Ministry of Public Health of Thailand and/or WHO.
2. A combined limit of 700,000THB applied to Outpatient and Inpatient benefits.
------------------------------------Attorney
For Claim, please call +66(0) 2650 1223 (TPA)
Other enquiries, contact us via enquiry@fwdgi.co.th