APPLICATION FORM (IE)

ISIS LANGUAGE INSURANCE



Applicant　
Last name ________________________________________________________________
First name _______________________________________ □ female　□ male
Date of birth _______________________________________ (day-month-year)
Address ________________________________________________________________
________________________________________________________________
Postcode ________________________________________________________________
City ________________________________________________________________
Country of origin ________________________________________________________________
Telephone ________________________________________________________________
Insured period from _______________________________ (day-month-year)
to _______________________________ (day-month-year)
Course fee ________________________________________________________________
Country of destination ________________________________________________________________
Language school ________________________________________________________________
Address ________________________________________________________________
________________________________________________________________
Postcode ________________________________________________________________
City ________________________________________________________________


Insured combination

　　　　　 　　Europe * 　　　 　　World　　　　　 　　Premium　　
Country of origin 　　□ 　　□　　　　　　　
Country of destination 　　□ 　　□　　　　　　　 　　EUR_________________
Hazardous / Winter sports 　　 　　□ yes 　　□ no　　　　　 　　EUR_________________
Additional luggage 　　□ yes 　　□ no　　　　　 　　EUR_________________
Total premium 　　　　　　　　　　 　　EUR_________________

* Europe premium if country of origin and country of destination are situated in Europe.


Please send this coupon to:

Nichiai Ltd
4 South Terrace,
Cork,
Ireland.