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Travel Insurance Application Form

Please complete this form

Lead Traveller's Detail
Title is required
Initials are required
Surname is required
Address Line 1 is required
Town/City is required
Postcode is required
Date of Birth is required
Email is required
Telephone is required
Additional Travellers to be insured
Cover & Premium Summary
Destination is required
Departure Date is required
Return Date is required
Declaration

Health Conditions Exclusion

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

  1. You are aware of any Medical Condition or set of circumstances that could reasonably be expected to give rise to a claim.
  2. 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.