Please print out the form, complete and post to: Adair Bungalows c/o La Becassine, Folie Lane, Vale, Guernsey. GY3 5SD with a cheque for the premium made payable to Channel Insurance Brokers Ltd. This cover is available to persons who are normally resident in the United Kingdom, The Isle of Man or the Channel Islands, for ordinary business or holiday travel which does not present any special hazard suck as visits to politically disturbed areas, hazardous or manual occupations. Period of Insurance Days/Weeks/Months ................................................................___________ Commencement Date...............................................................................................___________ Geographical Area...................................................................................................____2______ Do you want to delete Personal Baggage, clothing or effects, business samples and money cover? (20% discount if deleted) n.b. Delayed baggage remains in force..........___________ Name of Person to be insured..................................Age at Departure.....Premium _______________________________________...._________......_________ _______________________________________...._________......_________ _______________________________________...._________......_________ _______________________________________...._________......_________ Total Amount due (cheques payable to Channel Insurance Brokers Ltd) £_______ |
| IMPORTANT NOTICE. This insurance is conditional upon the trip or journey not being booked or commenced by any person to be insured contrary to medical advice, or to obtain medical treatment, or after a terminal prognosis has been made. When completing this application you should disclose any facts which may influence the acceptance of the risk. |
| Address of the first named insured person _______________________________________________________________ _______________________________________________________________ If any of the proposed insured has made an insurance claim during the past 3 years, please provide details on an attached sheet. Signature of first insured person (on behalf of all insured persons) ......................................Date ________________________________________________..................................._________
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