Travel Insurance Form

Title

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Full Name

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Full Address including postcode

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Proposer date of birth

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Will you be travelling to a location where the UK Foreign and Commonwealth Office has advised against travelling?

Yes
No

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Will you be involved in any Sports or Hazardous activities that are not included automatically by this policy (see list below) whilst away on your holidays?

You are covered to participate in the following sports and activities (provided you are not participating on a professional basis): angling, archery*, athletics* (not including marathon running), badminton, banana boating, baseball*, basketball, billiards, body boarding, bowling, boxing training (no contact), camel riding*, canoeing, catamaran sailing**, clay pigeon shooting, climbing (climbing wall), cricket*, croquet, curling, cycling (non-touring)*, dancing, darts, dinghy racing, dinghy sailing, elephant ride, fell walking, flag american football, football, golf, gymnastics, helicopter ride (passenger), hiking, horse drawn sleigh, horse riding, horse trekking, hot air ballooning (passenger), jet skiing*, kite surfing (on a lake)*, light aircraft rides (passenger), martial arts training, motorcycling under 125cc* (as a means of transport only), netball, orienteering, paint balling*, pony trekking, pool, rambling, rifle range*, ringos, rounders, rugby league*, rugby union*, sailing** (in-shore & off-shore), scuba diving (max. 30m), sledging, snooker, snorkelling, snow-shoeing, soccer, softball, squash*, surfing*, swimming, swimming with dolphins, table tennis, tennis, ten-pin bowling*, tobogganing (winter), touch football, trampolining, trekking, tubing, tug-o-war, volleyball, wake boarding, walking, walking up Sydney Harbour Bridge, water polo, waterskiing, wheelchair basketball, windsurfing (on a lake)*. * no Personal Liability cover ** no Personal Liability / offshore rescue cover You are NOT covered for any other Sports and Activities, unless declared to and agreed by us on your insurance schedule and an additional premium paid if required.

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Annual or single trip

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Please state when you would like the cover to begin (dd/mm/yyyy)

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If annual policy - Please state maximum amount of days per trip

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Area

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Number of persons travelling (Note: A family can be a maximum of two adults and up to 4 children)

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Please state when you would like the cover to finish (dd/mm/yyyy). Your policy will expire at 23.59 on this date

This is for single trips only

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Do you wish to include golf cover

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Do you wish to include winter sports cover

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Do you wish to include business cover?

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Do you wish to advise underwriters about anyone to be covered by this travel insurance having suffered from a medical condition or have you received any medication, advice or treatment for a medical condition within the last 12 months? This includes investigations,reviews and admissions relating to medical conditions, whether or not a diagnosis has been received.

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Do you wish to advise underwriters if you or anyone within this travel policy been diagnosed by a doctor or consultant as suffering from a terminal illness or have been advised against travel by your Doctor?

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We cannot extend cover for any persons who have been given a terminal prognosis or medical conditions relating to and 3rd parties on whom a trip may depend (e.g. a relative). Cancellation or curtailment claims relating to 3rd parties are only covered provided they have not suffered any medical condition in the last 6 months or 6 months before your trip was booked (whichever is later). Please confirm that you understand and agree.

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Details of additional holiday makers

Include - Full Name - Gender - Date of Birth - Are they in full time education - Are they the proposers spouse/Partner

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Any other information

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Telephone number

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E mail address

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How did you hear about us?

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