ANNUAL MULTI TRIP PROPOSAL FORM - Please Print off and send to Holiday Travel and Medical Ins.

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 by 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 the insureres when you take out your policy, throughout the life of the policy, and when you renew your insurance. Also check your policy details on receipt. 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 for pre-existing medical conditions unless declared and accepted by the Travellers Healthcheck Screening Line. Not valid for non UK residents ( at least one year in the UK ), one way trips or for anyone with a terminal diagnosis.

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

Signature ( must be over 18 ) ..........................................................................

TRAVELMASTER ANNUAL MULTI TRIP PROPOSAL FORM. Send to - Holiday Insurance, 8 Highfield Close, Loscoe, Derbyshire DE75 7LA. For the best rates, payment by chq. only payable to M Smith.

Please enter MR/MRS/MS/mstr/miss or Title before each first christian name.

Travel Area Required  [   ] Europe incl. Spain [   ]  Worldwide excluding USA/Canada/Caribbean/Mexico/Bermuda [   ] Worldwide including USA/Canada/Caribbean NB All areas are as defined on your policy wording, please check on receipt of your policy,

Start Date of Policy ( Max. one month in advance )  ..................................... PREMIUM £ ..............

Trip Length per Trip  31 days. ( if more days required please check with us )

Travelling as  [   ] Individuals  [    ] Couple as defined  [   ] Family  

Cover Options - NB No cover is provided for any cruise holiday unless cruise option has been selected.

[   ]  Normal AMT no cruise cover  [   ] Cruise cover single cruise  [   ] Cruise cover Multi Cruise

[   ] Extra cover for sporting activities ( please check with us if required ) [   ] £2  Single Applicant Charge

First Christian Name  .......................................... Surname .........................................

Date of birth  ...........................  Age as on start date of policy  ..............

First Christian Name  ...........................................  Surname ........................................

Date of Birth ............................. Age as on start date of policy   ...........

First Christian Name ..........................................    Surname .........................................

Date of Birth ........................... Age as on start date of policy    ..............

Travellers Healthcheck Ref. Number(s ) ..........................................................

All members of my party understand that they must be able to comply with the policy conditions, there is a 14 day money back guarentee.

Lead Name ............................................................ Address .....................................................................

............................................................................................................. Post Code ....................................

Tel.  ...........................................

e mail address ( must be correct )  ..............................................................................................

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

This 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, please read this when you receive your policy and contact us 01773 - 769406 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 where this is valid.