NAME/CONTACT DETAILS OF SENDER

Contact / Telephone No: *

E-mail:

NAME/CONTACT DETAILS OF POLICYHOLDER  

Policyholder First Name: *

Policyholder Last Name: *

MEDICAL DETAILS

Inpatient or Outpatient:

Time of admission / treatment:

Name of Hospital/treating facility:*

Address (including country in which it is located):  *

Name of treating doctor and or department:

Tel no:

E-mail:

Details of policyholder’s relevant Previous Medical History

TRAVEL INSURANCE DETAILS

Name of insurance / scheme: *

Policy No:

Policy valid from / to:

Policy issue date:

Where purchased:

Policy Lead name

Address of issuer:

Issuing agent’s Tel No:

OTHER INSURANCE

Airline

UK Airport

Overseas Airport:

If applicable details of other means of transport  (e.g. via train, car, coach etc):

Tour Operator:

Tour Operator Booking Reference:

Contact Details for local Tour Operator Rep:

Names and relationship of travel companions: