Insurance Form Name * First Name Last Name Email * Destination/s * Departure Date * MM DD YYYY Return Date * MM DD YYYY Number of Adults Travelling * Number of Children Travelling * Date of Birth of Adults * Date of Birth of Children * Choose your Cancellation Cover If you need to unexpectedly amend or cancel your trip for a covered reason before you leave home or while you’re travelling, our Amendment or Cancellation Costs benefit can reimburse you for the costs of any non-refundable, prepaid travel arrangements (such as transport, accommodation, or tours). Please Select $ 0 $ 1,000 $ 2,000 $ 3,000 $ 4,000 $ 5,000 $ 6,000 $ 8,000 $ 10,000 $ 15,000 $ 20,000 $ 30,000 $ 40,000 $ Unlimited Other Information to Disclose About Your Trip Cruise * Yes No Bike/Moped * Yes No Existing Medical Conditions (if Yes, please detail in Other Information) * Yes No Adventure Activities * Yes No Other Information Thank you!
