TRAVEL INSURANCE PROPOSAL FORM 

Please fully complete the form below and we will respond promptly.

Full Name  
Email Address    
Tele. Number    
Address Line 1    
Address Line 2
Address Line 3  
Post Code      
Give details of persons traveling   

Name

Age
Countries to be visited          UK only              Europe/ Countries bordering Med                 Worldwide
Period of Insurance          Short Period       Annual           
Dates of Travel (if applicable)  From                       To
Winter Sports Cover          Yes          No           
Baggage & Money Cover          Yes          No           
Cancellation Cover          Yes          No           
Are you and all persons traveling with you in good health, not awaiting an operation or other medical investigation. No-one traveling has received treatment for any blood disorder, any form of cancer, transplant, any psychiatric illness, dialysis treatment or dementia.           Yes          No    
If Yes Please give details :
What is the cheapest quote you have received so far and from which company: