BIMA Insurance Product Registration Form

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BIMA Insurance Product Registration Form

MILVIK (Cambodia) Micro Insurance Plc.

Address: 08th floor of the Phnom Penh International University Building, at No.36, Street #169, Sangkat Veal Vong, Khan 7 Makara, Phnom Penh.

Policyholder name

Age: *

Gender: *

Current Address:

Such as: House No.… Street… Group… Village… Commune / Sangkat ... District / Khan… Province / City

Customer NID:

Customer Phone Number:

Beneficiary Name:

Age:

Gender *

Beneficiary NID: *

Relationship with Customer:

Beneficiary Phone Number:

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