Travel Insurance Enquiry Form

Age of the oldest person to be insured

Is the policy only for yourself? Yes No

If No is the policy only for yourself/spouse/partner? Yes No

If No is the policy to include dependent children under 18? Yes No

Do those insured require cover outside Europe? Yes No

Do those insured intend to take more than one trip per annum? Yes No

What is the likely maximum duration of any one trip? Days

Does any insured person, or anyone on whom the trip may depend need to disclose any pre-existing medical condition? Yes No

Do those insured require cover for Winter Sports? Yes No

Do those insured require cover for any Hazardous Sport / Activity? Yes No
If yes please advise which Sport(s) / Activities

Please give details of any special requirements

Do not disclose any medical conditions at this time.

Please ensure that the benefits provided by the policy application forwarded to you meet your needs and requirements.

Should you wish to discuss your requirements further, please telephone our travel department between 9.00am - 5.00pm Monday - Friday on (020) 7739 3444