COMPLIMENTARY TRAVEL INSURANCE

Full Name*:

Mr Dr Ms Mrs Mdm

NRIC/Passport*:

Date of Birth*:

Mobile Number*:

You have charged your Full Fare to your*:

Select Citi Rewards Visa Signature Card Citi Rewards World Mastercard Citi Cash Back Visa Signature Card Citi Cash Back World Mastercard Citi Cash Back+ Visa Signature Card Citi Cash Back+ World Mastercard Citi Lazada Visa Signature Card

Date of Full Fare charged*:
(For this Complimentary Travel Insurance to be valid, travel dates must be within 6 months from the date of transaction when the Full Fare of your travel ticket was charged to the eligible Citi Card.)

You are travelling*:

Select Alone Together with my Spouse and /or Children

You will be required to fill in the Spouse's Details if you are travelling with your Spouse.

^*Kindly note: In the event that you have charged the Full Fare of your travel ticket to a Citi Card that is not under the above drop-down list of eligible Citi Cards, you will not be under coverage of this Complimentary Travel Insurance.

Travel Dates

Departure Date*:

Return Date*:

Important Notes:

• This Complimentary Travel Insurance is only applicable for your trip when you have charged the Full Fare of your travel ticket to the eligible Citi Card and have fully and accurately provided the information requested for in the form. Please refer to the Policy document to view the list of eligible Citi Cards and types of trips covered under the Policy.
• The maximum duration of coverage provided for any one round Covered Trip is 90 days.
• This Complimentary Travel Insurance is underwritten by HL Assurance Pte Ltd. By applying for this Complimentary Travel Insurance, you agree that (i) we may disclose your information to HL Assurance Pte Ltd in connection therewith (including but not limited to your application and processing of claims (if any) relating to this Complimentary Travel Insurance) and (ii) Citibank Singapore Limited or HL Assurance Pte Ltd may contact you via telephone or sms in relation to this Complimentary Travel Insurance.
• For claims involving the Insured Cardholder's spouse, he/she will only be covered if he/she is travelling on the same trip with the Insured Cardholder and the Full Fare for both the Insured Cardholder and his/her spouses is charged to the Insured Cardholder's Citi Card*.
• For claims involving Dependant Child(ren), Dependant Child(ren) means your legal child who is unmarried, between the ages of 15 days to 18 years or between the ages of 18 years to 25 years if the child is a full time student in a recognised tertiary institution or have been accepted and is awaiting enrolment as a full time student in a recognised tertiary institution.
• Your Citi Card* has to be in good standing order for you to be covered by this Complimentary Travel Insurance for the whole duration of your Trip and at the point of any claim thereafter.
• You are responsible for the completeness and accuracy of the information provided at the point of submission of your claim. HL Assurance Pte Ltd has the right to review and assess your claim before deciding on whether to process your claim, and the processing of your claim shall be at their sole discretion. HL Assurance Pte Ltd's decision on all matters relating to claims for the Complimentary Travel Insurance shall be final and binding on the claimants.
• Unless otherwise defined, all capitalised terms herein bear the same meaning as in the Policy.
• This is product information only and not a contract of insurance. Full terms, conditions and exclusions apply.