Travel Insurance Application Form

Please complete this form

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Lead Traveller's Detail

Title Title is required

Initials Initials are required

Surname Surname is required

Address Line 1 Address Line 1 is required

Address Line 2

Town or City Town/City is required

County

Postcode Postcode is required

Date of Birth Date of Birth is required

Email Email is required

Telephone Telephone is required

Additional Travellers to be insured

Name

Date of Birth

Cover & Premium Summary

Destination Destination is required

Departure Date Departure Date is required

Return Date Return Date is required

Declaration

Health Conditions Exclusion

We shall not be liable for claims where at the time of taking out this policy:

You are aware of any Medical Condition or set of circumstances that could reasonably be expected to give rise to a claim.
You:
1. Are receiving, or on a waiting list for, surgery, in-patient treatment or investigations in a hospital, clinic or nursing home.
2. Are travelling against any health requirements stipulated by the carrier, their handling agents or other Public Transport Provider.
3. Are travelling against the advice of a Healthcare Practitioner or for the purpose of obtaining medical treatment abroad.
4. Have been given a terminal prognosis.

Please note: If You are on medication at the time of travel, Your medical condition(s) must be stable and well controlled.

I Declare that I have read for myself and on behalf of those persons of whom I have arranged cover, the 'Health Conditions Declaration'. I confirm there are no circumstances that could be reasonably be expected to give rise to a claim.