StudentCare Application Form



  Important:

All personal details entered on this form will remain confidential to Interglobal Ltd and will not be disclosed to third parties nor will any detail or address be used for another purpose. Please ensure that you complete all appropriate boxes.

* means this is a required field.
 StudentCare - we'll look after you...
 


* Title
* Family Name
*Given Name
* Date of Birth  
* Home Country
 


 


* Current Street Address
* Suburb
* Home City/State/Province
* Country
* Post Code
* E-Mail
* Home Phone
Mobile Phone
Fax Number
 


 


*  Country of Study
*  Name of University/College
*  How long have you been in this country as a student?
*  How long do you intend to stay?
   Name of any agency (or N/A if none) who assisted/referred this application
 


 

Title Surname
First Name Date of Birth
Home Country
 


 


(Note: Date of Birth is required for all persons to be insured)
First Name Surname Date of Birth
First Name Surname Date of Birth
First Name Surname Date of Birth
 


 
Important Note:
 Pre-Existing Conditions - There is No Cover for any condition(s) which have occurred
or You are aware of two years prior to applying for this insurance.
 

 

* Period of Insurance From
* Cover Duration
* Region of Cover
* Policy type
* Premium Currency
 

  

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