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Travel Insurance Application Form

IMPORTANT: Please read the questions carefully because if they are not answered truthfully or you give any incorrect information, the insurance company may decide that your insurance is invalid and this may affect any claim you may make. Please supply us with any information that is not covered by the questions that you think might be relevant to the insurance.
Your Details
Title
Address
 
 
 
Post Code / BFPO No:
Contact Telephone No:
E-mail Address:
 
Are you resident in UK   Overseas
Cover Details
Is the cover for a Private Holiday
or Adventurous Training
Relationship    
Number of travellers:
 
Adult
Child
18 to 64
0 to 2
65 to 69
3 to 17
70 to 74
   
75 to 80
   
Over 80
    
 
Are there any pre-existing medical conditions within the family? Yes
Name
What is the Condition?
Name
What is the Condition?
Name
What is the Condition?
 
Travel Details
Type of Policy: Annual Multi trip
Annual Multi Trips
Which Area? Europe
Maximum Duration per trip? 45 days 90 days
Single Trips
Where is your destination?
Departure Date
Do you require cancellation due to unavoidable posting and/or duty? Yes No
Additional Travel Details
Will you be taking part in Hazardous Activities   Yes
If Yes What Activities
and it is for   Recreation   or Competitions
 
Additional Information
If you have any additional information to give please provide the details below
 
Would you like us to send you a quote by E-mail
   
 

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JBI International Insurance Brokers Ltd. are Authorised and Regulated by the Financial Services Authority. Our firm reference number is 308981.