HomeFormsTravel Insurance Enquiry Travel Insurance Enquiry Booking Reference (If Known) Event or Holiday If travelling for an event eg. NIO Bowls, Red Hatters or Spring Ukulele please confirm here.Passenger 1 Name: Passenger 1 Date of Birth: Day Month Year Passenger 2 Name: Passenger 2 Date of Birth: Day Month Year Street Address(Required) Address line 1 Address line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Email(Required) Phone(Required)Cover Amount(Required)$1000 (Solo Travellers)$2000$3000 (Solo Travellers)$4000$5000 (Solo Travellers)$6000$10,000Departure Date (date you leave for your holiday)(Required) DD slash MM slash YYYY Arrival Date (date you return home)(Required) DD slash MM slash YYYY 1. Do you require extra luggage cover eg. Golf clubs etc?(Required) Yes No 2. Do you require cover for snow skiing, snowboarding or snowmobiling?(Required) Yes No 3. Do you require Adventure Activity cover?(Required) Yes No 4. Do you require Motorcycle/Moped Riding cover?(Required) Yes No 5. In the last 12 months, have you been hospitalised or treated in the emergency department, seen a specialist, or had day surgery?(Required) Yes No 6. Are you taking prescription or over the counter medication to treat, control or prevent their condition? Eg. insulin for diabetes, aspirin for strokes, Paracetamol for back pain?(Required) Yes No 7. Have you got a chronic, ongoing or reoccurring condition eg. arthritis or back pain?(Required) Yes No 8. Have you ever had a medical condition or required surgery or any of the following:(Required) Yes No Kidneys/Liver Cancer (even in remission) Joint, back or spine Brain eg. Dementia, Epilepsy, head injury, tumours Any heart-related condition eg. angina, bypass surgery, heart attack, irregular heart rhythms, stents Strokes eg clots, Deep Vein Thrombosis, mini strokes, Pulmonary Embolism Respiratory system eg. Chronic Bronchitis, COPD, Emphysema9. Are you pregnant?(Required) Yes No 10. Are you experiencing any signs or symptoms where a medical diagnosis has not been sought? Eg. chest pain, shortness of breath, a persistent cough or unexplained bleeding.(Required) Yes No Δ HomeFormsTravel Insurance Enquiry ShareTweetPinShareEmail0 Shares
