Holiday Travel and Medical Insurance is an Appointed Representative of Infinity Insurance Solutions, a trading name of Milsom Howard Ltd who are authorised and regulated the Financial Services Authority (FSA).The policy is underwritten by URV who are authorised and regulated by the FSA and are members of the Financial Services Compensation Scheme.NB  It is your responsibility to provide complete and accurate information to insurers when you take out an insurance policy, throughout the life of the policy, and when you renew your insurance.  It is important that you ensure that all statements you make on proposal forms, statements of fact, claims forms and other documents are full and accurate.  You should note that if you fail to disclose any information or change in circumstances to your insurers which could influence the cost, or their decision to accept your insurance, this could invalidate your insurance cover, and mean that part or all of your claim may not be paid.  It should be noted that there is no cover on the policy for  pre-existing medical conditions of any traveller named on the policy, or of relatives upon whom the trip may depend, unless declared and accepted by the Travellers Healthcheck Screening Line. Not valid for non UK residents ( at least one year in UK ), one way trips or for anyone who has been given a terminal diagnosis.   

Do you understand and on this basis are happy to proceed ? Yes, I understand the above -

  

Signature ( must be over 18 ) ....................................................... Please enclose this with your proposal form

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HOLIDAY TRAVEL & MEDICAL INSURANCE PROPOSAL FORM

Send to -  Holiday Insurance, 8 Highfield Close, Loscoe, Derbyshire DE75 7LA. Payment by chq. payable to M Smith.

Please enter Mr/Mrs/Miss/MS/Mstr/Miss or title before first Christian Name.

First Christian Name:  ....................     

Surname: ..................................

Age on start day of travel:  ..........     Date of Birth: ....................

First Christian Name:  .................... 

Surname: ..........................

Age on start day of travel:  .........      Date of Birth: ....................

First Christian Name:  ....................

Surname: ..........................

Age on start day of travel:  .........      Date of Birth: ....................

My trip starts on: ........................   

Date of Return to UK:  ....................

Number of days cover required:  ...........                                   (include the date of return landing in the UK)

Areas you are covered for (please tick as required) 

[  ]UK   [  ]EUROPE   [  ]USA/CANADA/BERMUDA/MEXICO/CARIBBEAN 

[  ]REST OF THE WORLD           [  ] AUS/NZ *STOPOVER RULES APPLY  

Actual destination(s): ..................................................

Single applicant Charge (payable if only one person insuring)                      Add £2 Premium  [  ] Yes  [  ] No

Optional Extra Cover [  ]  Excess Waiver  [   ] Cruise 2000  [   ]                   

[  ]Extra cover for sporting Activities  TOTAL PREMIUM £ ............

Travellers Healthcheck Reference Number. Must begin TPGT followed by your number 

Name ..................................  Ref...........................

Name ..................................  Ref ..........................

All members of my party understand that they must be able to comply with the    policy conditions.  There is a 14 day money back guarantee (less £2   admininistration

Lead Name: ........................

Address: ..........................     ....................................

County: ...........................     Postcode: ..........................

Telephone:  .......................

Email Address: .............................................................

Signature on behalf of all persons insuring (must be over 18) -

Signature ...............................................

 The insurance is based on the information supplied on the form and no responsibility can be accepted for information incorrectly supplied.  The cover is based on the full policy wording enclosed with your certificate. Please read this when you receive your policy, as there are limits, conditions and exceptions as in the wordings of your policy. Please check your policy certificate on receipt and contact us if you have any queries or there are any errors.  Note - The EHIC (European Health Insurance Card). Please ensure that you take this with you when travelling to those countries.