Travel Insurance Needs Analysis
Broker Email Address - a copy of the form will be sent to this address
*
example@example.com
Client Reference
*
Date of Enquiry
-
Day
-
Month
Year
Date
Policy Due Date
-
Day
-
Month
Year
Date
Current Insurer
Who referred client to RIB?
Sales Team
Insured Details
Insured Person #1
Name
First Name
Last Name
Gender
Please Select
Male
Female
Date of Birth
-
Day
-
Month
Year
Date
Insured Person #2
Name
First Name
Last Name
Gender
Please Select
Male
Female
Date of Birth
-
Day
-
Month
Year
Date
Insured Person #3
Name
First Name
Last Name
Gender
Please Select
Male
Female
Date of Birth
-
Day
-
Month
Year
Date
Insured Person #4
Name
First Name
Last Name
Gender
Please Select
Male
Female
Date of Birth
-
Day
-
Month
Year
Date
Insured Person #5
Name
First Name
Last Name
Gender
Please Select
Male
Female
Date of Birth
-
Day
-
Month
Year
Date
Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: 0000000000.
Email
example@example.com
Destination
Departure Date
-
Day
-
Month
Year
Date
Return Date
-
Day
-
Month
Year
Date
Number of Travellers
Excess
Plan Selected
Please Select
Double
Single
Super Plus
Deposit Protection
Super
International
Economy
Standard
Period of Journey
Days
Weeks
Months
Dependant Children Travelling with Adults
Child #1
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Child #2
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Child #3
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Child #4
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Child #5
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Country or region spending majority of the trip
Claims History
For last 5 years
Claim #1
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim
Amount
Claim #2
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim
Amount
Claim #3
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim
Amount
Cost of Trip In Case of Cancellation (Flights & Accommodation)
Duty of Disclosure
Rows
Yes
No
Has the insured ever had insurance cancelled, declined, or special conditions imposed?
Has the Insured ever been convicted of, or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property in the last 5 years?
Has the insured ever been declared bankrupt and not discharged within the last 12 months?
Are there any exceptional circumstances relating to the risk to be insured that you have not already told us about and that you know or should know may affect the Insurer’s decision to accept the insurance?
Are you spending more than 72 hours in the USA, South or Central America or Antarctica?
Do you have a pre-existing medical condition?
Do you require cover for your pre-existing medical conditions? If yes, complete Pre-Existing Medical Application
If Yes, Provide Full Details
Broker Recommendations
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