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Quotation Request

Travel

Main Details
Travellers
Traveller 1
Traveller 2
Traveller 3
Traveller 4

Main Details

Please enter the Policy Holder's name below.
Please enter the Policy Holder's full address below:
Enter the Policy Holder's email address below:




When would you like the cover to start ?
HIDDEN: Cost Per Person
£
How old is the oldest Traveller ? (years)
age is to be at time of departure
Do you want to include Winter Sports cover?
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Commencement Date of trip
Return Date

Travellers and Health Questions

Number of people to be Insured ?
Please include children under 2 on the date of departure.
In the last 5 years has anyone travelling suffered from:
A cardiovascular or heart related condition (hypertension, angina, chest pain, heart attack and the like)?
A circulatory or renal condition, diabetes or cancer whether in remission or not.
A lung respiratory related condition (not including asthma when it is controlled and you have no other medical condition)
A psychological or psychiatric condition such as stress, anxiety, depression, dementia, malaise, fatigue (burn-out syndrome).
A stroke, brain stroke or TIA (Transient Ischemic Attack) or other cerebrovascular condition.
A terminal condition.
In the last 2 years has anyone to be insured:
Taking currently or taken or been told to take regular medication.
Taking prescribed medication for a chronic and/or recurring condition.
Required an organ transplant or requires dialysis.
Sought, or should have sought medical advice before taking this trip or is travelling against the advice of a medical practioner.
Having or waiting to have any investigations of any type?
Knows that medical treatment will be required during the trip or is travelling to obtain medical treatment of any kind whilst abroad.
Are you or any traveller to be insured aware of any medical condition affecting a relative, business associate, travelling companion or someone you are going to stay with which could result in the trip being cancelled or curtailed?

Traveller 1

Full Name
Date of Birth
Does the traveller have any pre-existing medical conditions?

Traveller 2

Full Name
Date of Birth
Does the traveller have any pre-existing medical conditions?

Traveller 3

Full Name
Please select traveller Date of Birth
Does the traveller have any pre-existing medical conditions?

Traveller 4

Full Name
Please select traveller Date of Birth
Does the traveller have any pre-existing medical conditions?