Travel Insurance Application Form At Voluntours we believe that your safety and enjoyment when travelling overseas are very important.Therefore travel insurance is a must whenever you travel abroad. If you require travel insurance you may wish to contact specialist Insurance Brokers Campbell Irvine, underwritten by AXA Insurance (UK) plc*. To arrange cover or to obtain a quotation please contact Campbell Irvine on Tel: 020 7938 1734 Fax: 020 7938 2205 Or email: email@example.com Travel Insurance Summary of Cover (per person) A Medical Expenses In Patient Benefit £10 per day up to Criminal injuries £100 per day up to Personal Liability £5,000,000 £200 £ 5,000 £2,000,000 D Delayed Departure or Arrival Either compensation up to OR cancellation after 12 hours up to Hi-jack of Aircraft £100 per day up to Failure of flight connections £25 per day up to Interruption of Transport E Personal Effects (Valuables limited to £350) (Single Article limit £250) (Disc Collections £200) Money Tickets Passport and Visas F Legal Expenses G Winter Sports £100 £1,000 £3,000 £150 £300 £2,000 B Personal Accident Permanent Loss of Sight Loss of Limb(s) Permanent Total Disablement Death £25,000 £25,000 £25,000 £25,000 £10,000 C Cancellation or Curtailment £3,000 £500 £1,000 £250 £15,000 Optional Premiums To obtain a quotation please contact Campbell Irvine. Please note cover for certain activities may be subject to an increased premium. Baggage and Money Discount 20% Discount if you choose not to have baggage and money cover. If you already have a household policy this may cover your personal baggage and money whilst you are travelling overseas. If you check and find this is the case then you may wish to exclude this from your travel insurance. Age 66 years or more - For persons aged 66 years or more at the time of arranging insurance double the standard rates apply. Maximum age 69 years old at date of payment of insurance premium, unless agreed by the insurers. Cancellation Cover If you require the cancellation cover to be increased from the standard £3,000 per person, please contact Campbell Irvine for a quotation. Cancellation cover starts immediately after your application and payment is received. Please note that this insurance specifically excludes the cost of any medical treatment incurred in an insured person's country of residence. PREMIUMS per person from: Single Trip – Adult up to 66 Years old Up to 4 days Up to 9 Days Up to 17 Days Up to 24 Days Up to 32 Days Up to 45 Days Worldwide Annual Multi Trip – Adult up to 66 Years old Children aged 18 years or less Up to 28 days Winter Sports Europe £17 £21 £27 £37 £46 £70 Individual £99 Free £28 Worldwide excl North Worldwide incl. North America America £45 £66 £52 £79 £59 £87 £66 £97 £72 £103 £110 £146 Individual plus Spouse £159 Free £28 The above premiums include Government imposed Insurance Premium Tax. Currently at 17.5%. All premiums shown are valid for policies issued up to 31/12/2009. IMPORTANT This is only a summary of cover, full details of the cover provided are shown on your policy document which will be sent to you at time of booking, please read it carefully to ensure you understand the cover provided as this insurance is being offered on a Non Advised basis from a single insurer Axa Insurance UK plc. In addition policy includes certain terms conditions, exclusions and excesses. In particular cover is excluded for any pre-existing medical condition from which you or any person upon whom travel depends are suffering. If in doubt please contact our medical helpline in confidence on 0844 892 0954, as additional cover may be purchased directly from the insurer’s medical screening help line for certain pre-existing medical condition. Please contact the medical screening helpline for guidance and advice. Should you wish a specimen, a copy will be made available prior to purchase upon request. The policy document contains a 14 day Cooling Off Period and details of how to claim and who to contact in the event of a medical emergency. *Registered in England. No. 78950. Registered Office, 5 Old Broad, London EC2N 1AD. A member of the AXA Group of Companies. AXA Insurance UK plc. Registration No 202312. Both Campbell Irvine and Axa Insurance are authorised and regulated by the Financial Services Authority. This can be checked on the FSA's register by visiting the FSA's website at www.fsa.gov.uk/register or by contacting them on 0845 606 1234. Travel Insurance Application Form To arrange cover please complete this application and send it to Campbell Irvine at: 48 Earls Court Road, London W8 6EJ or Tel: 020 7938 1734 Fax: 020 7938 2250 or Email: firstname.lastname@example.org NAME(S) OF PERSONS TO BE INSURED: Title First Name Last Name Age Premium £ Total Premium including Insurance Premium Tax ADDRESS: (In BLOCK CAPITALS) Postcode: Email: SINGLE TRIP INSURANCE: Departure Date: ……………….. Return Date: ……………. Telephone: £ Period of Insurance: ………………… Days or months GEOGRAPHICAL AREA(S): Please tick which Area(s) you are travelling to: Area 1 Area 2 Area 3 Area 4 UK Europe Worldwide ex. North America Worldwide inc. North America Please tick if you wish to delete Section E Personal Effects Accompanied Personal PERSONAL EFFECTS: Luggage, Money, Tickets and Passport / Visa, Baggage a discount of 20% will be allowed. INCLUDE WINTER SPORTS: ANNUAL MULTI TRIP INSURANCE: (Worldwide including North America cover) Maximum duration 70 days any one trip limited to 31 days if aged 66 years or more. (Commencement date is the date of receipt of application in respect of Annual Multi Trip policies) PERSONAL EFFECTS: Please tick if you wish to delete Section E Personal Effects Accompanied Personal Luggage, Money, Tickets and Passport / Visa, Baggage a discount of 20% will be allowed. INCLUDE WINTER SPORTS: (up to 28 days in total) PAYMENT DETAILS: I wish to pay by: Cheque: or Card: Please charge to the Card indicated the sum of £……………………. (All cheque to be made payable to Campbell Irvine Ltd). Card Holders Name: ……………………………………………………………………………. Card Number: ………………………………………………… Valid From: ……………… Expiry Date: ……………… Security No: ……………… Date of Application: ……………… e.g. (31/12/2009) Issue Number: (Maestro only) ……………… Please tick here to confirm that you have read and understood the Policy Document which details the cover provided. Please note the Policy contains certain exclusions and limitations especially relating to cover for any Pre-existing Medical Condition from which you or any person upon whom travel depends, is suffering. If in doubt call our medical helpline, in confidence, on: 0844 892 0954 (Please see definition of Pre-existing Medical Conditions in the Policy Document. Please also see General Exclusion 9 in the policy for further details.) IMPORTANT: Data Protection This insurance is underwritten by AXA Insurance UK plc, who are authorised and regulated by the Financial Services Authority. Your insurer AXA Insurance UK plc is a member of the AXA Group. To set up and administer your insurance policy they will hold and use information about you supplied by you and by medical providers. They may also send it in confidence for processing to other companies in the AXA Group (or companies acting on their instructions) including those located outside the European Economic Area.