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Travel Insurance

Please complete the details below and note that cover is NOT effective UNTIL you have received written confirmation from us.

Salutation

* First Name

* Last Name

* ID or Passport

* Daytime Phone

* Email

Fax

Date of Birth

Month of Birth

Year of Birth

Insurance Details

Start Date

No. of Days

Type of travel

1105, 11th Floor, Two Pacific Place 142 Sukhumvit Rd, Klong Toey, Bangkok 10110, Thailand. Hotline: 0 2653 2994 Fax: +66(0) 2254 6757 Email: info@lfsinsurancethailand.com