Cotation

APERSON TO BE INSURED

As the policyholder to the Plan, you are the legal representative towards StudyProtect of the person to insure included on this application form. The policyholder may choose not to be insured if cover is required for dependant only.

Name of the school*

BPREMIUM/ TERM

1. Specify the effective date desired (dd/mm/yyyy)*

(At earliest at noon, the day following the receipt of your application)

2. Choice of option*

Option 1: StudentCover Swiss zone Option 2: StudentCover Worldwide

3. Choose your deductible plan (in CHF)*

100 300 500 1000

4. Please select the frequency of your premium*

Yearly Half-yearly (every 6 months) Quarterly (every 3 months) Monthly (every month)

Email address*

APERSON TO BE INSURED

Name of the school*

Title*

Civil Status*

Gender*

Birthdate (dd/mm/yyyy)*

Address*

BPREMIUM/ TERM

1. Specify the effective date desired (dd/mm/yyyy)*

2. Choice of option*

3. Choose your deductible plan (in CHF)*

4. Please select the frequency of your premium*

Thank you

StudyProtect Team.