Emergency Medical Evacuation Program

An emergency medical evacuation program coverage from Global Assistance Jakarta, available for expatriates and Indonesians residing in Bali.

1 Medical Evacuation Program for Single IDR 2,925,000
2 Medical Evacuation Program for Couple IDR 4,394,000
Couple should be member and his/her spouse only
3 Medical Evacuation Program for Family IDR 5,850,000
Couple should be member and spouse only
and up to 4 (four) dependent children

Note :
1. Terms and conditions apply for medical evacuation program
2. Members are covered up to max of 70 years old
3. Prices are subject to change without prior notice
4. This membership program is non transferable and non refundable
5. Temporary cannot be combined with BIMCare Membership program

For further information on its terms and conditions, please contact nusadua@bimcbali.com

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MEMBERSHIP APPLICATION

GENERAL INFORMATION
Name*
Date of Birth*
Address*
Postal Code*
State*
Country*
Home Phone*
Home Fax*
Office Phone*
Office Fax*
Occupation
Company

INCLUSION OF SPOUSE AND/OR CHILDREN FOR COUPLE/FAMILY MEMBERSHIP
Name (Spouse)*
Date of Birth (Spouse)*
Occupation
Company
Name (Child)*
Date of Birth (Child)*
Name (Child))*
Date of Birth (Child)*
Name (Child)*
Date of Birth (Child)*

DECLARATION:

  1. This Application is subject to the Warranty that Member/s is/are in good health at the time of obtaining cover and there are no medical conditions in existence which may require emergency transportation by Global Assistance & Healthcare®.
  2. This Application is subject to the Warranty that Member/s will not book or commence any journey contrary to medical advice, or with intention to obtain medical treatment of after a terminal prognosis has been made.
  3. The Application is subject to the Warranty that Member/s are under 70 years of age at the Commencement of Membership or at the start of any subsequent journey.
  4. This Membership is subject to the General Conditions which are included in the General Terms and Conditions attached.


INCLUSION OF SPOUSE AND/OR CHILDREN FOR COUPLE/FAMILY MEMBERSHIP
Membership Type
Membership Number
Membership Validity
to

BIMC Hospital Nusa Dua
The first hospital in Indonesia with accreditation from Australian Council on Healthcare Standard International  (ACHSI)

Your Name*

Your Email*