Specialist Travel Insurance Application Form
Personal Details
Name(s) of persons to be insured:
*
UK Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postcode
UK Home Address:
*
UK Home Postcode:
*
Telephone:
*
Format: 00000000000.
Email:
*
Travel Details
Departure Date:
*
-
Day
-
Month
Year
Return Date:
*
-
Day
-
Month
Year
List of countries/territories to be visited:
*
Is your trip booked with a UK tour operator?
*
Yes
No
Name of the UK tour operator/organisation:
*
Please provide details of all known security arrangements:
Please confirm the primary purpose of your trip:
*
Business
Pleasure
Name of UK-registered company travelling on behalf of:
*
Please state the nature of business/occupation:
*
Please detail any additional policy requirements:
e.g. increased personal accident cover
Please provide a copy of your full trip itinerary including accommodation details:
How would you like to provide your itinerary?
*
Upload a file
Link a file
Please upload a copy of your itinerary:
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Please link a copy of your itinerary:
*
Submit
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