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U.K. RESIDENTS

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Travel Insurance Application Form

Your Details

Title InitialsSurname

Address

Post Code / BFPO No:
Contact Telephone No:
E-mail Address:

Are you resident in UK Overseas
If Overseas are you residing within the EU? YesNo

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 No

Name		What is the Condition?
Name		What is the Condition?
Name		What is the Condition?

Travel Details

Type of Policy:

Annual Multi trip or Single trip

Annual Multi Trips

Which Area?

Europe Worldwide

Would you like baggage Cover?

Yes No

Maximum Duration per trip?

45 days 90 days

Single Trips

Where is your destination?

Departure Date //Return Date//

Additional Travel Details

Will you be taking part in Hazardous Activities Yes No

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 Fax Postor Phone you

www.jbionline.com is owned and operated by JBI International Insurance Brokers Ltd. Registered in England - Reg. No. 1936834. Registered Office: Andromeda House, Aldermaston, Reading, Berkshire RG7 8AP United Kingdom.

All telephone calls are recorded for training and monitoring purposes.

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