Apply for Travel Medical Insurance

Membership Number

1. Please Fill In Your Personal Details

Ensure to write your names as they appear on your passport
Note that the maximum number of travel days covered per dependant is 90 day per annum/year
Maximum age limit for travel insurance cover is 80 years old

2. Please Indicate Your Health Plan

This benefit is only applicable on extra and max health plans

Health Plans

Access

Comprehensive

Executive

Prestige

Level of Cover

Extra

Max

Section A: Principal Members Details

Title

First name (s)

Surname

Date of Birth

Email Address

Mobile Number

Passport No

Section B: Travel Details

Date of Departure

Date of Return

Departure Country

Destination Country

Section C: Travelling Dependants Details

Re-order	Title	First names (s)	Surname	Date of Birth	Passport No	Weight	Operations
	Title	First names (s)	Surname	Date of Birth	Passport No	Item weight

more items

Section D: Member Declaration

I understand that, to assess my application and provide the requested travel insurance coverage, BOMAID is required to collect, process, and share my personal
information (including special categories of personal data such as health and medical information, travel details, and financial information) with the insurance
company/underwriter that underwrites and issues the policy (“the Underwriter”)

I acknowledge that:
The processing and sharing of my personal information is necessary for the performance of the insurance contract (or to take steps at my request prior to
entering into the contract) in terms of Section 26(b)of the Data Protection Act (No.18 of 2024).

Where special categories of personal data (in particular health data) are processed, this is done under Section 30(2)(b) of DPA and or other applicable
exemptions available to insurance undertakings.

The Underwriter (or its authorised representatives) may contact me directly by telephone, email, text message, or post in connection with the underwriting,
issuance, administration, claims handling, or servicing of this policy.

I confirm that the information I have provided is true, accurate, and complete to the best of my knowledge.

I have read and understand the above statement:

Please fill out this form if you intend to seek medical services while out Botswana

NOTE:
All emergency medical services accessed while travelling outside Botswana will be covered by the Travel Insurance. Please refer to your travel insurance policy document for more information how to submit those claims. You may fill out this form and email it to bomaid@bomaid.co.bw before you access non-emergency medical services while outside Botswana The following are services for which pre-authorisation must first be sought before treatment: Hospitalization, Specialized radiology (CT, MRI, Nuclear medicine, PET scans), Appliances, Chemotherapy and Radiation therapy, Renal dialysis, Specialised dentistry, Orthodontic treatment. Requests for pre- authorisations must be emailed to casemanagement@bomaid.co.bw

Name Of Principal Member

Membership Number

Member Declaration

Re-order	Patient Name	Membership No.	Type of service e.g maternity delivery/ dental services / optical services	Expected Date of service	Country of sevice	Weight	Operations
	Patient Name	Membership No.	Type of service e.g maternity delivery/ dental services / optical services	Expected Date of service	Country of sevice	Item weight

more items

CLIENT INFORMATION CONSENT

I understand that in order to assess my application and provide the requested travel insurance coverage, BOMAID is required to collect, process and share my personal information (including special categories of personal data such as health and medical information, travel details and financial information) with the insurance company/underwriter that underwrites and issues the policy( the Underwriter).

I acknowledge that:

The processing and sharing of my personal information is necessary for the performance of the insurance contact (or to take steps at my request prior to entering into contact) in terms of Section 26(b) of the Data Protection Act(No.18 of 2024).

Where special categories of personal data (in particular health data) are processed. This is done under Section 30(2)(b) of DPA and or other applicable exemptions available to insurance undertakings.

The Underwriter (or it's authorised representatives) may contact me directly by telephone, email, text message or post in connection with the underwriting, issuance, administration, claims handing or servicing of this policy.

I confirm that the information I have provided is true, accurate and complete to the best of my knowledge.

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