Multi-trip Travel Insurance

Policy holder's name: Address:
Email: Telephone Number:
Commencement: (00/00/00) Area to be visited:
       
Name 1: Date of Birth: Medical condition? Yes No
Name 2: Date of Birth: Medical condition? Yes No
Name 3: Date of Birth: Medical condition? Yes No
Name 4: Date of Birth: Medical condition? Yes No
Name 5: Date of Birth: Medical condition? Yes No
Name 6: Date of Birth: Medical condition? Yes No
       
Baggage cover required? Yes No Additional comments:
Winter Sports cover? Yes No
Dangerous activity cover? Yes No
Dangerous sports include Scuba diving, Mountain Biking and surface watersports.

Richard Anthony Oakes, Sharon Linda Oakes & Ashley Burton trading as Oakes Insurance Consultants are
authorised and regulated by the Financial Services Authority. Number 307170

Registered office: Oakes House, Derby Road, Long Eaton, Nottingham NG10 1PD