Coversure International Insurance

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*Name

Email*	Contact Number*

Nationality	Region of Coverage

Region of Residence	Length of Coverage

Type of Coverage	Maternity
Hospitalization Cover	I require maternity benefits
I require outpatient benefits	Dental
	I require dental benefits

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35th Floor,
1 Hung To Road,
Kwun Tong,
Hong Kong

Tel: +852 3113 2112

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