Travel Plus Adventures Application

Applicants Copy

Certificate No. TPA

Thank you for choosing the Travel Plus Adventures scheme for your Travel Insurance requirements. Cover will commence as soon as the Issuing Agent has validated this application. Your attention is drawn to the IMPORTANT NOTICE - MEDICAL CONDITIONS AND MATERIAL FACTS overleaf.
PLEASE COMPLETE THE WHITE BOXES IN BLOCK CAPITALS

Title	MrMs.Mrs.MissDr. Initials Surname Age/DoB
Address:	Post-Code: Telephone No.
E-Mail:

Title	Initials	Surname	Age/DoB
MrMs.Mrs.MissDr.
[Add Person]

Parts A & B
Departure Date	Return Date	No. of Days
Part A Only
Activity Begins	Activity Ends	No. of Days

Activity:	Adventures Category: 2. American Football, Boxing, Farm Work, Flying – As a Pilot or passenger in an unlicensed aircraft, Gliding (Not Learning), Go Karting, Kite Surfing, Motor Cycle Touring, Motor Rallies Other than major events, Parascending Over Land, Polo (Not Competitive), Quad Biking, Sand Boarding, Wakeboarding, Wrestling, Martial Arts, Amateur contact sports e.g. Rugby. 3. Diving over 30 metres (With appropriate qualifications), Flying/Gliding Learning to Fly/Glide, Hot Air Ballooning, Manual Work(Up to 9 metres above ground/Hazardous machinery, Martial Arts (Competitive) Motor Track/Off Road Motorcycling Not competitive, Overland Trips in Africa, Asia or Latin America (over 2 days), Yatching involving Racing/Crewing/Tall Ships/Ocean Crossing (Excluding all or part of round the world trips). 4. BMX Cycling (Competitive), Canyoning, Glacier Crossing/Walking, Hang Gliding, Horse Jumping/Polo Not Competitive Micro Lighting, Air Boarding Sky Surfing, Motor Cross, Parachuting Paragliding Paragliding Para Motoring Parasailing Parapenting Paraointing Sky Diving, Potholing / Caving, Rock Climbing Winter Sports Bobsleigh/Skeleton, Winter Sports Heli-Skiing/Ski touring, Winter Sports Ice Hockey, Winter Sports Racing in Major Events, Winter Sports Stunting/Freestyle/Acrobatics/Jumping, Ski Instructors, Shark Diving, Trekking to 6000m, Mountaineering in Europe or Kilimanjaro. NOTE: Category 4 Activities shown in RED above can only be covered in UK or Europe. Please state here which particular activity(ies) are to covered Part "A" only Parts "A & B"
Area:	Europe Worldwide Excluding USA, Canada & Caribbean Worldwide Including USA, Canada & Caribbean	THE PREMIUM (per person)	Premiums Part "A" £ Part "B" £ Total £

Please debit my VISAMASTERCARDSWITCH (MAESTRO) card with £
Card No: Security Code: Card Valid From: Card Expiry Date:
Cardholder´s Name:
Address (if different from above):

Declaration (Applicant) I declare to the best of my knowledge and belief I have advised you of all material facts (any fact which is likely to influence the rate or cover to be provided by the Underwriting Agents) and that I have read the Important Notice-Medical Conditions and Material Facts. I understand that you may exchange information with other insurers or their agents to check the answers I have provided and you have my authority to do so.

Issuing Agent´s Declaration (if applicant not present) I confirm that I have read out the declaration (opposite) to the Applicant who has confirmed that they fully understand the terms and conditions of the policy and have authorised me to sign it on their behalf.

You will not be covered:

1. Where at the time of taking out this insurance the person whose condition gives rise to a claim:
   1. is receiving, or is on a waiting list for in-patient treatment in a hospital or nursing home; or
   2. has received a terminal prognosis; or
   3. is travelling against medical advice or for the purpose of obtaining treatment; or
   4. is expected to give birth before or within fourteen weeks of the date of arrival home;
   5. is suffering or has suffered, from any diagnosed psychiatric disorder, anxiety of depression.
   Note: The above exclusion applies not only to you, but also to close relatives or other persons on whom the trip depends.
2. For trips outside your home country where at the time of taking out this insurance you answer "yes" to any of the "Medical Screening Questions" below, and fail to contact the Medical Screening Line.

Medical Screening

If you need to telephone the Medical Screening Line, you will be asked simple questions about your medical condition, medication, trips to the doctors, and other related matters.

In most cases, cover is provided under normal terms. If, as a consequence of your call, we wish to impose special terms, these will be advised to you immediately, and confirmed in writing.

Please note terms may vary depending on destination, period of travel and other factors.

Medical Screening Questions

		Yes	No
I)	Within the last year have you been treated as a hospital in-patient or been under the care of a specialist consultant or been referred to a specialist consultant?
II)	Have you ever been treated for a breathing or heart related condition (including angina)?
III)	Have you ever been diagnosed with cancer?
IV)	Have you ever been diagnosed with a circulatory condition (e.g. DVT)?

If you have answered No to all questions you do not need to call the Medical Screening Line

If you have answered Yes to any of the questions please telephone the Medical Screening Line on 0845 230 5555 between the hours of 9.00am to 5.00pm Monday to Friday to confirm acceptability of cover. (Please note: Mondays are normally very busy. You may prefer to call at other times.

Note: You do not need to phone the Medical Screening Line if your trip is within the United Kingdom, or if you have one of the following conditions (provided you are not on a waiting list for treatment): Acid reflux, Acne, Arthritis, Asthma (but only if well controlled by using inhalers) Colds or "flu", Dyspepsia, Eczema, Gall Stones / Gall Bladder Removal, Glaucoma, Gout, Hay-fever, Hernia, Hyperthyroidism (over-active thyroid), Hypothyroidism (under-active thyroid), Irritable bowel syndrome, Meniere's disease, Migraine, Psoriasis, Tonsillitis, Varicose veins.

I confirm that I have read and understand this important information and now wish to proceed with this insurance.