APPLICATION FORM - SINGLE TRIP TRAVEL INSURANCE Cancellation cover shall commence at the time of each individual trip being booked and the other sections of cover on commencement of a booked trip. A Certificate will be issued and sent to you within a few days.
NAMES OF PERSONS TO BE INSURED | Age | Premium per Person | | 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | . . . . . . . | . . . . . . . . .. . . . . | | 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | . . . . . . . | . . . . . . . . .. . . . . | | 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | . . . . . . . | . . . . . . . . .. . . . . | | 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | . . . . . . . | . . . . . . . . .. . . . . | | 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | . . . . . . . | . . . . . . . . .. . . . . | | 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | . . . . . . . | . . . . . . . . .. . . . . | TOTAL PREMIUM £
(inclusive of insurance premium tax) | | . . . . . . . . .. . . . . |
| ADDRESS OF FIRST NAMED (in BLOCK CAPITALS) | | . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | | . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | | Postcode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Telephone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . | | Period of Insurance . . . . . . . . . . . . . . . . . . . . . . days/months | | Commencement Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . |
| GEOGRAPHICAL ZONE | |  | | Area 1: | UNITED KINGDOM | | | Area 2: | EUROPE | | | Area 3: | WORLDWIDE EXCLUDING NORTH AMERICA | | | Area 4: | WORLDWIDE | | | | Include Winter Sports | | | | I wish to delete Baggage and Money cover | |
The Geographical Areas and stop-over periods are outlined in the policy description. | AMENDMENTS | | | BUSINESS TRIPS. Non-manual Business Trips are automatically covered by Single Trip Travel Insurance. | | | DELETE BAGGAGE & MONEY. 20% Discount if Baggage & Money sections are deleted. |  |
IT IS WARRANTED
1. The trip or journey for which this insurance is effected is not booked or commenced by an insured person(s):
(a). Contrary to medical advice or to obtain medical treatment (b). Suffering from any medical condition or symptoms which are waiting or receiving investigation, treatment, tests, referral or review or the results of any of the foregoing. 2. No insured person is aware of any reason why travel may be cancelled or curtailed.
3. Age limit 66 years unless the appropriate additional premium has been paid at the time of booking.
PLEASE NOTE: Cover is excluded 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.
For full details of definitions and Terms and Conditions of this Insurance please see the policy description. TO: CAMPBELL IRVINE LTD. Please charge to the Credit Card indicated the sum of £ . . . . . . . . . . . . . .
| Tick one: | | Expiry Date
Month Year |
Card No | | VISA | |  |  | | MASTERCARD | | | | | MAESTRO | | | | | Issue Number (Maestro only) | . . . | . . . . . . . . . . . . . . . | | | I enclose a cheque | | Cheques should | be made payable to Campbell Irvine Ltd |
Card Holder's Signature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date . . . . . . . . . . . . . . .
MATERIAL FACTS Please remember that all Material Facts should be disclosed (see detailed policy description) as failure to do so may affect your rights under this Insurance. In particular you should disclose any serious medical condition that may require treatment during a period of overseas travel or that might cause you to cancel the trip. Complete the application form, and send it with payment of the premium to:
Time For Travel, Long Hoyle, Heyshott, Midhurst, West Sussex, GU29 0DX. | 
