Who is Traveling? * First Name Last Name Date of Birth * Day-Month-Year MM DD YYYY Email * Phone * Country (###) ### #### Residential Address * This is where you live now Address 1 Address 2 City State/Province Zip/Postal Code Country Which Of Our Partners Are You Traveling With * Where Are you Travelling * Click as many as applicable UK & Europe North America South America North & Central Asia South Asia Australasia Expedition Travel What Country Do you Normally Live In? * Are You Already Traveling? * Please note if you are already travelling, you MUST select this option otherwise your Policy is not valid. No Yes, We can offer travel insurance for you if you've left home and already travelling but only on the strict understanding that nothing has already happened which has led to a claim or may lead to a potential claim. Choose Your Travel Start Date * MM DD YYYY Choose Your Travel End Date * MM DD YYYY Do You Require Coverage For Adventure Sport * Inc Rock-climbing, Mountaineering to 6,000M with (with ropes, picks or specialist climbing equipment) etc No Yes Do You Require Coverage For Snow Sports * Please select this option if you will be skiing or snowboarding on your trip. No Yes You must declare any pre-existing medical conditions you may have. If you fail to declare any medical conditions, this may mean any claim you may need for medical treatment abroad may not be covered. Please remember to declare even minor conditions, which normally would not attract any additional premium. * Thank you! Travel Insurance
