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Type of enquiry

NAME

Phone Number

Home address

Building Sum Insured/Value

Content Sum Insured/Value

Personal Effect Value (optional)

NAME

Phone Number

Date of Birth

Option of Coverage
a. Inpatient onlyb. Inpatient and Outpatient

Dental Coverage
a. Yesb. Noc. Maybe

Deductible Option
a. Yesb. Noc. May be

Budget
a. Under Bht 30,000b. Bht 30,000 to Bht 50,000c. Doesn't have budget

NAME

Phone Number

Date of Birth

Travel Policy
a. Annualb. By trip Policy

Departure Country (For trip Policy)

Destination (For trip Policy)

Period of Insurance (For Trip Policy)

NAME

Phone Number

Date of Birth

Purpose of buying Life (can choose more than 1)

a. Tax Deductibleb. Savingc. Life Protectiond. Pension

Period of Premium Payment

a.Less than 10 yearsb.More than 10 years

Premium Budget per year

a. Under Bht 30,000b. Bht 30,000 to Bht 50,000c.More than 100,000

NAME

Phone Number

Date of Birth

Occupation

Sum Insured / Limit of Indemnity
a. 300,000 Bhtb. 500,000 Bhtc. 1,000,000 Bhtd. 3,000,000 Bhte. 5,000,000 Bht

Would you like to cover medical expense?
a. Yesb. Noc. May be

NAME

Phone Number

Date of Birth

Occupation

Sum Insured / Limit of Indemnity

a. 300,000 Bhtb. 500,000 Bhtc. 1,000,000 Bhtd. 3,000,000 Bhte. 5,000,000 Bht

NAME

Phone Number

Car Brand

Car Model

Car Year

Car's Cubic Centimeter (CC.)

Type of Policy

a. Comprehensive Policyb. Third Party Liability Policy

OUR LOCATION

Infinity Insurance Broker (Thailand) Co., Ltd., Dusit Thani Building, 946, 10th Floor,
Room 1004, Rama IV Road, Silom, Bangrak, Bangkok 10500 Thailand

CONTACT INFORMATION

Email: info@infinbroker.com
Tel: +66 2 2672792-4
Fax: +66 2 2672795

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