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Travel Insurance Premium Quotation Request Form
Applicant's Personal Details
From: TEL No: Location: Office:		Email : FAX No: Home:
Applicant's Personal Details
Please Complete the following details : 1 Insured's Full Name 2 Number of Additional Family Members -Select- 0 1 2 3 4 5 6
Name of the family additional member a b c d e f		Age Relationship to Insured
4 Address (Incl. P.O.Box) 5 Telephone 6 Place of Travel From To : 7 Period of Travel(DD/MM/YY) From To : 8 Period of Insurance Coverage -Select- 1 week QAR 55.00 2 weeks QAR 75.00 3 weeks QAR 95.00 1 month QAR 115.00 2 months QAR 170.00 3 months QAR 290.00 1 year(max stay 90 days) QAR 570.00
Notes
1	Policy can be delivered within Qatar for an additional fee of QR.25/-	Yes No
2	Policy once issued is non - Refundable
Declaration:
	I/We agree to accept insurance subject to the terms and conditions of the TraveCare Insurance policy documents issued by the company
Travel Insurance Premium Quotation
FOR QIC OFFICIAL PURPOSE ONLY
Price Quote Calculation Premium Policy Fees Delivery Fees (if applicable) TOTAL PREMIUM     QIC Contact Details email: onestop@qic.com.qa Fax: +974 4831569 Quote valid for 3 Days when signed and stamped (not applicable for email quotes)
Travel Insurance Premium & Benefits Table
Premium Table Premium Table Travel Duration Premium Per Person Limit per Person Up to 1 week - QAR.55.00 1. Medical Expenses - USD.55,000 Up to 2 weeks - QAR.75.00 2. Personal Accident - USD.25,000 Up to 3 weeks - QAR.95.00 3. Loss of Personal Baggage - USD.1,200 Up to 1 month - QAR.115.00 4. Loss of Passport - USD.500 Up to 2 months - QAR.170.00 5. Cancellation/Curtailment - USD.1,000 Up to 3 months - QAR.290.00 6. delayed Baggage - USD.300 Up to 1 year (max.stay 90days) - 570.00 7. delayed/Missed Departure - USD.2,500   8. Personal Legal Liability - USD.100,000