Travel Insurance Quotation

Name

Address

Postcode

Email Address

Daytime Telephone Number

Date of Birth

Type of Cover

Destination

Dates of travel

Type of cover required

Applicant 2 Name

Date of Birth

Relationship to Applicant

Applicant 3 Name

Date of Birth

Relationship to Applicant

Applicant 4 Name

Date of Birth

Relationship to Applicant

Do you require Baggage and Money cover

Do you require cover for any Winter Sports activities

Have you required consultation or treatment in the last 12 months for any serious, chronic or recurring medical conditions

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?

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)?

Has any insurer refused to give you travel insurance in the last three years?

Have you ever been convicted, or charged (but not yet tried), in respect of any criminal offence involving dishonety, fraud, violence, criminal damage, drugs or arson, or have been given a Polcie Caution in respect of any of these offences?

If you have answered yes to any of the above questions or would like to give further information please give full details here.