Please fill in the information below. Alternatively, if you would like to print off and post to us, please download the form here.
Completed questionnaires are in consideration of the removal of the war exclusion to Sections A – Medical Emergency and Section C – Personal Accident only – No cover is provided under this insurance for any political evacuation.
Your Name (required)
Your Email (required)
Your Telephone Number (required)
Dates of travel
Names and Certificate number(s) (if known) of those to be covered under the war risk
Date of Birth
What Country will you be visiting? (required)
AfghanistanChadChechnyaDemocratic Republic of CongoIraqIsrael (west bank and Gaza Strip)Ivory CoastLibyaNigeriaSomaliaSudanSouth SudanSyriaYemen
What is the purpose of your trip? (required)
Will you be working for a charity / missionary group? (required)
have you travelled to this country / location before? (required)
Will you be met at the airport / escorted at all times? (please provide full details on the security arrangements provided) (required)
Where will you be staying? (eg. hotel, guest house) and are security arrangements in place? (please provide full details) (required)