Specialists in… Personal Accident, Travel and Liability cover. Group Travel Quote Submission Form This cover is available to companies normally resident in the United Kingdom* or the Channel Islands for ordinary business and holiday travel that does not present any special hazard such as visits to politically disturbed areas or manual occupations. Agent's Email Address Group Enquiry for: Business: Basis of cover:DirectorsDirectors and EmployeesOthers (i.e. volunteers, members or sub-contractors, please advise)Named Person(s) Only: (complete box below) Named persons / others e.g volunteers, members or sub-contractorsInsert the total number of trips for each person to each destination, split by duration band (e.g. 2. persons travelling together = 2 trips) Business Travel Pattern: No of tripsUKEuropeUSA and CanadaRest of the World1-4 days5-7 days8-14 days15-21 days22-28 days29-45 days46-60 days60-90 days Holiday Travel Pattern: No of trips UKEuropeUSA and CanadaRest of the World1-4 days5-7 days8-14 days15-21 days22-28 days29-45 days46-60 days60-90 daysUnited Kingdom includes England, Scotland, Wales, Northern Ireland and the Isle of ManEurope includes Southern Ireland, the Channel Islands, the Azores, Madeira, the Canary Islauds, Morocco, Tunisia, Israel, Mediterranean Islands, Turkey. Black Sea Resorts and Cornmonwealth of Independent. States west of the Ural MountainsNorth America includes the United States of America, Canada and the Caribbean lslands Do the above travel patterns include trips for spouses and dependent children of Directors? *YesNo Do the above travel patterns include trips for spouses and dependent children of Employees?*YesNo Are any persons to be insured normally resident outside the United Kingdom? *YesNo Will any of the trips involve manual work or hazardous activities? *YesNo Are any of the trips to be insured likely to exceed 3 months duration? *YesNo Are any of the persons to be insured over the age of 65 years at inception? *YesNo Are the sums insured on the next worksheet sufficient? (If not, amend where shown below)*YesNo Any travel to Afghanistan, Central African Republic, Chad, Chechnia, Cuba, Democratic People’s Republic of Korea (North Korea), Egypt, Iran, Iraq, Israel but only the West Bank Gaza, Ivory Coast, Kenya, Libya, Mali, Nigeria, Pakistan, Republic of Sudan, Republic of South Sudan, Russia, Syrian Arab Republic (Syria), Somalia, Ukraine and Yemen?*YesNo Have there been any claims in the last 3 years? (If so, give details where shown below) *YesNo If the answer to any of these questions is yes, please provide details below: CLAIMS RECORDCLAIM 1 Declaration: If yes to any of the above - please provide details: CLAIM 1Provide InformationYearSection Amount PaidCircumstances CLAIM 2Provide InformationYearSection Amount PaidCircumstances CLAIM 3Provide InformationYearSection Amount PaidCircumstances CLAIM 4Provide InformationYearSection Amount PaidCircumstances CLAIM 5Provide InformationYearSection Amount PaidCircumstances Section Sum Insured (requested) if differentEmergency medical expenses - Up to £10,000,000Employee replacement expenses - Up to £3000Journey continuation -Up to £500Travel delay - Reasonable expensesPersonal Liability - Up to £2,000,000Legal expenses - Up to £25,000Personal accident - Up to £50,000Hospital Benefit - Up to £1,500Emergency evacuation expenses - Up to £25,000Personal baggage, clothing and effects - Up to £3,000Personal money - Up to £1,000Business samples - Up to £1,000Delayed baggage - Up to £300Loss of passport - Up to £500Hi-jack, kidnap and detention - Up to £15,000Car Hire Excess Waiver - Up to £250Cancellation and curtailment - Up to £5,000Emergency return to the United Kingdon or country of normal domicile - Up to £1,000SubmitReset BrokersAccident & Illness Contractors Liability Tools &/or Business Equipment Travel Login Username Password Forgot your password? Login
