| Under 18 years |
| 18-64 |
| 65-74 |
| 75-80 |
| 81- and above |
| 50% of the premium |
| Normal Rating as above |
| 100% additional Premium |
| 200% additional Premium |
| No cover |
| Premiums |
| USD |
| 1-5 days |
| *50 |
| 6-10 days |
| 11-15 days |
| 16-20 days |
| 21-35days |
| 26-31days |
| each additional week there of |
| 45 days any one trip |
| * Add policy fee |
| Age Structure |
| *Winter sports may be covered at an extra 100% premium, but excluded for any insured age 65 and above. |
| *60 |
| *80 |
| *100 |
| *125 |
| *150 |
| *10 |
| *300 |
| * 1.00 |
| Group and Corporate rates available on request |
| WORLDWIDE TRAVEL INSURANCE |
| SELECT AND PROTECT |
| Under written by INTRA AFRICA ASSURANCE CO LTD. Services Povides by : INTERNATIONAL SOS ASSISTANCE (UK) LTD. |
| On arrival this is the information you are required to have.Please submit to us before. NOTE: THIS TRAVEL INSURANCE IS NOT EFFECTIVE UNTIL ACCEPTED BY THE UNDERWRITERS UNTIL AND THE POLICY HAS BEEN ISSUED. |
| PROPOSED INSURES FULL NAMES |
| OCCUPATION |
| PASSPORT No. |
| DATE OF BIRTH. |
| FAMILY RELATIONSHIP WITH FIRST PROPOSER |
| Full Residential Address |
| Postal Address |
| Name of Next of Kin |
| Telephone Office and Home |
| Relationship |
| Date of Departure |
| Date of Return |
| Length of Trip, No. of Days |
| Contacts for next of kin |
| Medical Emergency Claims: A 24 hour medical emergency claims services is provided worlwide through International SOS Assistance (UK) Ltd.- Help is just a telephone call Away |
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