Register your travel agent account

Register Travel Agent

Please fill company details.

Kind Of Business

Company Name

Company Legal Name

Address

Phone Number

Fax Number

Optional

Website

Optional

Contact Email

Bank Name

Optional

Bank Account Number

Optional

Bank Account Name

Optional

PKS File

File perjanjian kerja sama. PDF File. Optional.

Sales Agent Information

Please fill main user account for the travel agent. This account will be used to login into Zurich Travel Insurance as travel agent. You can add another user after your application has been approved.

Please make sure your email address is correct.

Password

Password length at least 8 characters, must be alphanumeric and contains at least has one upper case and one lower case.

Name

Mobile Number

Phone Number

Optional

Address

City

Zip Code

Optional

Place of Birth

Optional

Date of Birth

Personal ID No. (KTP)

Optional

I hereby confirm the statements contained in this form are correct. I have read, understood and agreed to the term and conditions herein.

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