| Please take a moment to fill out this form and one of our brokers will contact you shortly to offer you a quotation or discuss your requirements further. |
| Title | * | | |
| First name | * | | |
| Second/middle name | | | |
| Surname | * | | |
| Date of birth | * | | |
| Place of birth | * | | |
| Sex | * | | |
| What is your occupation | * | | |
| Are you self employed | * | | |
| What is your employers business | | | |
| Name or number of your home | * | | |
| Postcode | * | | |
| Do you own or rent this property | * | | |
| E-mail address | * | | |
| Daytime contact number (including code) | * | | |
| Evening contact number (including code) | | | |
| Mobile contact number (including code) | | | |
| How did you hear about us | * | | |
| When do you need this insurance to start | * | | |
| | (this date should be the date you leave home to start your trip) | |
| How many months cover do you need | * | | |
| Where in the world are you travelling | * | | |
| Do you require extra “stop over” cover (cover is automatically provided for ‘stop-overs’ of up to 7 days maximum in a higher rated area e.g. travelling to New Zealand via the USA. This can be extended to a maximum of 31 days on payment of an additional premium) | * | | |
| All policies will have an excess, do you want to pay to remove this | * | | |
| If you need cover for additional activities refer to the list below and enter additional activities here | | | |
| Do you want cancellation cover | * | | |
| Do you want cover for personal belongings | * | | |
| Who do you need to be covered | * | | |
| What is the age of the oldest person travelling | * | | |
| What is the age of the youngest person travelling | * | | |
| Do you or anyone travelling have any existing medical conditions | * | | |
| STANDARD ACTIVITY - Cover is automatically included for the following: | | Archery, Adventure Training and Outward Bound, Abselling to 50m, Amateur non-contact sports (e.g. golf, cricket), Bungee Jumping, Canoeing/Kayaking (not white water), Cycling and Mountain Biking, Fencing, Fishing/Angling,Go Karting, Horse riding (excluding competitions), Ice Skating, Jet Skiing (note no liability cover), Motorcycling (in line with UK licence entitlement), Parascending, Rafting (including white water), Safari and Overland trips, Sailboarding/Windsurfing, Sailing/Yachting (but not ocean racing), Scuba and Sub Aqua to 9m, Snorkelling, Surfing, Trekking (below 5,000m), Water Skiing, Winter Sports (other than as shown below), Work (non-manual/clerical and manual work but not involving Ski Resort occupations, heavy equipment, heights in excess of 9 metres, working underground or special exposure to risk). | |
| ADDITIONAL ACTIVITY - The following are covered if you have paid the activity premium:
| | American Football, Amateur contact sports (e.g. rugby, football, hockey), Ballooning, Flying in a single-engined aircraft, Gliding, Hang Gliding, Ice Hockey, Micro-lighting, Martial Arts, Mountaineering & Rock climbing up to 5,000m, Paragliding, Parachuting and Skydiving, Scuba and Sub Aqua to 30m, Trekking (above 5,000m), Winter Sports (including Ski Resort occupations, working abroad, Bobsleigh, Skeleton (Cresta), Ski Touring, Stunting, Freestyle, Acrobatics, Jumping). | |
| If the intended activity is not shown above, please contact us. |
| Privacy and Data Protection | | The Rossborough Group holds your details in accordance with relevant Data Protection Law in the UK, Isle of Man and Channel Islands. Some or all of the information you supply to us in connection with your insurance proposal will be held on computer and may be passed to insurance companies for underwriting and claims purposes. In addition, we may use some of the information to advise you of other products and services offered by the Rossborough Group. If you do not wish to receive such details please contact our Compliance Officer. | |