Privacy Policy

Details of Proposer

Name
Address
Telephone

Date of Birth   Email Address Nationality NIF / Passport Occupation
Where did you hear about us * Please Select *GoogleExisting ClientRecommendationLink from another siteIntroducer4Business MagazineEuro Weekly NewsAlgarve ClassifiedAlgarve Daily NewsBingBritish Chamber of CommerceFacebookInstagramKiss FMLinkedInMailshot RadioTwitterOther

By completing the below you are agreeing for us to contact you to discuss your insurance needs.

  We would also like to keep in touch with you about our products and services. If you would like to receive marketing information about other insurance products from us please tick this box giving your consent. We hope that you find them useful however if you wish to withdraw your consent at any point please let us know and we will remove you from our marketing database

 

Privacy Policy

Insurance Details

Gender

 Male    Female

Quote for

 Myself    Myself and my partner

Partner Gender

 Male    Female

Partners Date of Birth

Number of children (under 21)

Please select... 0 1 2 3 4 5 6

Please confirm Gender & Date of Birth of each other traveller

*N/A* Male Female

*N/A* Male Female

*N/A* Male Female

*N/A* Male Female

*N/A* Male Female

*N/A* Male Female

Select area of cover

 Europe
 Country of Residence only
 Worldwide
 Worldwide excluding USA and Canada

Additional cover

 Dental

How would you like us to reply to you?

 Email    Post    Phone

Do you currently have health insurance cover?

 Yes    No

If so, with whom?

Would you like details of our Company health plan ?

 Yes

Intended principal country of residence
This is the country where you intend to live for more than 6 months in any one year. Please note, this is not your country of origin.

Albania Algeria Andorra Armenia Australia Austria Belgium Bosnia-Herzegovina Bulgaria Canada Croatia Cyprus Czech Republic Denmark (and Faroe Islands) Egypt Estonia Federation of Serbia and Montenegro (and Kosovo) Finland France Germany Gibraltar Greece Greenland Hungary Iceland Ireland Israel Italy Latvia Lebanon Libya Liechtenstein Lithuania Luxembourg Macedonia Malta Moldavia Monaco Morocco Netherlands (excl. all Overseas territories) New Zealand Norway Poland Portugal Romania Slovac Republic Slovenia South Africa Spain (inc. Balearics, Canaries, Ceuta & Melilla) Sweden Syria Tunisia Turkey United Kingdom United States of America

Queries or Comments

How do you prefer to make payment

 Monthly    Annually