COMPANY DETAILS
Company Name:
Contact Name - Title & Surname:
Contact Name - First Name:
Business Address:
Postcode:
Contact Number:
E-mail Address:
Business Description:
Number of Years Trading:
Renewal Date (if applicable):
Target Premium (£):
COVER REQUIRED
Insured Persons:
If All Directors & Employees, please give names of those requiring holiday trip extension:
If Specified Travelers, please give details:
Name
Age
Holiday Extension
Winter Sports
   
(please check box)
(please check box)
1.  
Yes
Yes
2.  
Yes
Yes
3.  
Yes
Yes
4.  
Yes
Yes
ANTICIPATED TRAVEL PATTERN
Destination
No of Trips
Average
No. of Days
Maximum
No. of Days
   
1.   U.K. / U.K.
2.   E.U.
3.   USA / Canada
4.   Rest of World
Details of Any Manual Work:
Additional Information:
ADDITIONAL INFORMATION
Please provide details of ALL and ANY losses you have suffered or claims you have made in the last five years (please advise date(s), cost(s) and circumstances:
Any additional information/comments or material facts that may affect an insurers willingness to offer cover:
Standard exclusions: 1) Hazardous Sports & Pastimes & 2) Pre and Existing medical injuries
Thank you for completing your details - please press the submit button for a quotation.