TIS: Travel Insurance - On-line Application/Quotation Form
TIS: Travel Insurance - On-line Application/Quotation Form
Full Name (1)
*
Date of Birth
Date of Birth
*
/
DD
/
MM
YYYY
NIE /Passport Nº.
*
Tel./Mob. Number(s)
*
Email
*
Address
*
Post Code
*
Full Name (2)
Date of Birth
Date of Birth
/
DD
/
MM
YYYY
NIE (2)
Full Name (3)
Date of Birth
Date of Birth
/
DD
/
MM
YYYY
NIE (3)
Full Name (4)
Date of Birth
Date of Birth
/
DD
/
MM
YYYY
NIE (4)
Full Name (5)
Date of Birth
Date of Birth
/
DD
/
MM
YYYY
NIE (5)
Multiple Choice
*
Multiple Choice
Single Trip
Annual Multi-trip
18 mth YOung Traveller (<35 yrs old)
18 mth Long Stay (<75 yrs old)
Departure Date
Departure Date
*
/
DD
/
MM
YYYY
Return Date
Return Date
/
DD
/
MM
YYYY
Destination :
*
Destination :
Europe
Worldwide (ex USA/Canada)
Worldwide
Include Cover for Winter Sports ?
*
Include Cover for Winter Sports ?
NO
YES
Medical declaration completed ?
*
Medical declaration completed ?
NO
YES
Credit Card Number
Expiry Date (MM/YY)
Any Comments, Questions or Suggestions :
Data Protection/Ley de Protección de Datos
*
Data Protection/Ley de Protección de Datos
I agree to the sending and retention of this personal data in compliance with The Data Protection Act. / Estoy de acuerdo con el envío y la retención de estos datos personales de acuerdo con la Ley de Protección de Datos.
Type the letters you see in the image below.