Travel Insurance Form
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Title
Full Name *
E mail address *
Telephone number
Ages of travellers *
Annual or single trip *
Area *
If a single trip, start date (dd/mm/yyyy) and finish date (dd/mm/yyyy)
If annual policy - Please state maximum amount of days per trip
Full Address including postcode
Will you be involved in any Sports or Hazardous activities that are not included automatically by the 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.
Do you wish to include golf cover
Do you wish to include winter sports cover
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.
Any other information
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