FM-PRO 12-110

Duty Stamp Paid

5211970164
Reference No.

MB9039

Insurance Certificate
-
This document is a part of the Travel Accident Insurance for Domestic Policy (Cover Round Trip)

Certificate No. : 2/89/14/142586

MTI
Company Code
Booking No. : 13462728
1. : The Policyholder : Name and Address
() Nok Airlines Public Company Limited
183 17 10120
183 Rajanakarn Building, 17th floor, South Sathorn Rd., Yannawa, Sathorn, Bangkok 10120, Thailand
2. : The Insured : Name and Address
SARANPHOD YAPHONG
742/60
MUANG 90100 TH
3. : The Beneficiary : Name and Address
Heir at law
4. : Hat Yai Airport - Don Mueang Airport, Don Mueang Airport - Hat Yai Airport
Journey :
5. :

11:15 .

19:35 .
11/06/2014
11/06/2014
Period of Insurance :
From
at
hours.
To
at
hours.
30 30 30
The company provides a maximum coverage of 30 days since the travel date. If the trip takes more than 30 days, the coverage will be provided
only for the first 30 days.

In case of informing airline for changing travel date, the insurance coverage will effect only for insureds actual travel period which has been informed.
6. :
Limit of Liability : This certificate affords coverage only which a sum insured is stated.

()
()
()
Insuring Agreement
Sum Insured (Baht)
Deductible (Baht)
Premium (Baht)

As per list attached

As per list attached
Net Premium

139.19

Stamp
VAT
Total Premium

1.00
9.81
150.00

7. / Insuring Agreement/Endorsement attached

Agent

;
Broker

243/2529
License No.
05/06/2014
05/06/2014
Agreement made on
Certificate issued on

As evidence, the Company has caused this policy to be signed by person/s with power to act on behalf of the company and the company's stamp to be affixed at
its office.

..............................................
( )
Nualphan Lamsam
- Director

Supreme Broker Co.,Ltd.

..............................................
( )
Kritaya Lamsam
- Director

..............................................

Authorized Person