Personal Travel Insurance – Form

Please Enter the Details as described on your Personal Travel Insurance
(Please note this is confidential)

(required*)

Motorcycle Tour Name (*)

Name of Policy Holder / Riders Details

Your Telephone Number (*)

Riders Title (*)

Rider's First Given Name (*)

Rider's Middle Given Name's:

Rider's Surname Name (*)

Riders Date of Birth (*)
- -

Are you a Diabetic (*)

Do you as a rider have any pre-existing Medical Condition

Please Declare the condition to us (Please note this is confidential)

Pillions Details

Pillions Title

Pillion's First Given Name

Pillion's Middle Given Name's:

Pillion's Surname Name

Pillion's Date of Birth
- -

Are you a Diabetic

Do you as a Pillion have any pre-existing Medical Condition

Please Declare the condition to us (Please note this is confidential)

Travel Insurance Company Details

Travel Insurance Company Name (*)

Insurance Company Main Contact Telephone Number (*)

Insurance Company Emergency Contact Telephone Number (*)
(in case of a medical emergency)

Insurance Company Address (*)

Insurance Certificate Number / Ref (*)

Travel Insurance Start of Cover Date (*)
- -

Travel Insurance End of Cover Date (*)
- -

Insurance Territorial Limits (*)

Type of Insurance (*)

Personal Activity Insurance Cover (*)

Anything you wish to add that we should know about...

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