Travel Phone First Name Last Name Email Address Phone Number NIE Number Date of Birth Postcode How many people need cover? Date of Birth Person 01 Date of Birth Person 02 Date of Birth Person 03 Date of Birth Person 04 Date of Birth Person 05 Date of Birth Person 06 Type of Policy Single Trip Annual Both Date of Travel (if applicable) Where will you be travelling? Europe Worldwide - Including USA/Canada/Caribbean Worldwide - Excluding USA/Canada/Caribbean Do you have any pre-existing medical conditions? Have you started taking medication or had a change in dosage within the last 2 years? Yes No Have you EVER been diagnosed or treated for any of the following conditions and if so please supply date Any heart or circulatory condition A stroke, TIA (transient ischaemic attack) or high blood pressure A brain haemorrhage A breathing condition (including asthma) Any type of cancer Any type of diabetes If yes to any of the above please provide dates & a brief description How can we help?