If you had previous certitificate, you can query data here

OR

Cross Border Insurance

GEOGRAPHICAL COVERAGE
  • This insurance policy is covered within the Kingdom of Cambodia

Premium :

USD

*Note: This premium is non refundable.

Company Name :
Company Contact Number :
Driver Name :
Driving License Number :
Passport No./ID card :
Date of Birth :
Occupation :
Nationality :
Address :
Post Code :
Phone No. :
Email :
Vehicle Type :
Make/Model :
Chassis No :
Engine No :
Year of Manufacture :
Vehicle Plate Number :
Engine Capacity :
Seating Capacity :
Weight Capacity :
Country (where vehicle is departing from) :
Province (where vehicle is departing from) :
Border Gate :
Registration Country :
Purpose of Use :
Policy Period :
Effective Date :
Expiry Date :
Premium Charge :
GEOGRAPHICAL COVERAGE
  • This insurance policy is covered within the Kingdom of Cambodia

*Note: This premium is non refundable.

DECLARATION AND ACKNOWLEDGMENT
I/WE DO HEREBY DECLARE AND WARRANT the information provided above in every respect are true and correct, and I/we have not withheld any information likely to affect acceptance of this Proposal, and I/we agree that this Proposal and Declaration shall be the basis of the Contract between the Company and myself/ourselves, and I/we further agree to accept the Company’s Policy subject to the terms, exclusions and conditions to be expressed therein endorsed thereon or attached thereto.