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Travel Submission Form

Broker's Name Broker's Contact No

Policy Required

Single Trip Policies
 Annual multi trip Travel policies Annual travel policies including winter sports
Snowsport policy Business Annual Multi-trip Long-stay & backpackers

Travel Plus Adventures
(includes hazardous Pursuits & Activity holidays) 		UK Plus Travel Plus Overseas (for those working abroad)
European motor breakdown cover Travel Plus for Expats Group travel insurance

General Questions

Proposer

Partner

 
If joint cover is required, please complete both sections.

Title: (Mr/Mrs/Miss/Ms/Dr etc.)

 
First Name(s):
 

Surname:

 

Gender:

 

Age:

 

Client Address




Postal Code:

Contact Telephone No’s.:

Day:

Mobile:

Email Address:

Start Date:

Any pre-existing conditions?

Premium indication will be based on the information obtained from your client. Clients will be asked to provide all material facts - Failure to do so may invalidate their policy

Members of B.I.B.A

Authorised and regulated by the Financial Services Authority
A UNITAS Broker