Traveller’s details

    Please enter the details of the traveller applying for existing medical condition cover.

    Title* First name* Last name* Age* Date of birth*

    Email Address*
    Re-Enter Email Address*

    Trip details

    Please enter your travel dates and select the area you will travel to.For a list of countries and areas click here
    Start date*
    Annual Multi-Trip Only
    Area of travel*

    Please confirm that the policyholder has:*

    • been made aware of how their personal information will be collected, used and disclosed as described in the Privacy Notice
    • provided their express consent to us obtaining the requested health information to assess and price the travel insurance
    • confirmed that where they are providing information about other individuals, they have informed these individuals of the personal information they are providing, have obtained their consent to providing the information and the third party understands how their information may be used and disclosed

    All fields marked by * are mandatory