Wednesday 10 March Web Site Introduction About MSM Insurance Motor Services Kit & Specialist Car Build-Up Cover Kit & Specialist Car On Road Cover Classic Car Smart Car Motor Breakdown Domestic Services Travel / Holiday Insurance Home Buildings / Contents Insurance Commercial Commercial Services Interactive Manufacturer Links Kit Car Manufacturers Definitive Directory Other Links Refer us to a friend Contact us at MSM	First Applicant's Details: Title:          Forename(s):  Surname:  Date of Birth:  // Address:  Home telephone:      Mobile:  E-mail address:  Travel Policy Details: Type of cover required:  Single trip /Annual Multi-trip/Long stay Single Trip departure date:  // return date:   // Which area are you travelling to:  UK / Europe / Rest of the world (excluding countries listed) Australia and New Zealand / USA, Canada and Caribbean / Annual Multi-trip (policy valid for 1 year from start date) Which area are you travelling to:  UK and Europe / Worldwide (excluding USA and Canada) / Worldwide (any country) Long Stay (policy valid for 1 year from start date) departure date:  // Number of months abroad (3 - 15):  Which area are you travelling to:  UK / Europe / Rest of the world (excluding countries listed) Australia and New Zealand / USA, Canada and Caribbean Type of cover required:  Individual /Family /Couple Additional names to go on policy Full Name:                 Date of Birth:  // Relationship to applicant:  Full Name:                 Date of Birth:  // Relationship to applicant:  Full Name:                 Date of Birth:  // Relationship to applicant:  Full Name:                 Date of Birth:  // Relationship to applicant:  Do you require Baggage and Money cover?   Yes /No   Do you require cover for any Winter Sports activities?   Yes/No   Are you aware of any reason why any holiday or journey could be cancelled or abandoned?   Yes/No   Have you required consultation or treatment in the last 12 months for any serious, chronic or recurring medical condition?   Yes/No   Will you be booking a holiday or journey solely for the purpose of taking part in any activity, or do you intend taking part in an activity that involves an element of risk e.g. safari, scuba diving or team sport?   Yes/No   Have you made any travel claims in the last three years (if yes please give details of claim date, description and the amount of the claim)?   Yes/No   Has any insurer refused to give you travel insurance in the last three years?  Yes/No   Have you ever been convicted, or charged (but not yet tried), in respect of any criminal offence involving dishonesty, fraud, violence, criminal damage, drugs or arson; or been given a Police Caution in respect of any of these offences?   Yes/No If you have answered Yes to any of the above questions please give full details here:
MSM Insurance, P.O. Box 5526, Takeley, Bishop's Stortford, Herts CM22 6PZ Telephone: 01279 870535                  Fax: 01279 870636                  E-mail: info@msminsurance.co.uk