	Gothic Insurance Brokers Ltd Gothic House Station Rd, Old Harlow Essex CM17 0AP Tel – 01279 429024 Fax – 01279 433383 Email – enquiries@gothicinsurance.com

or call

Authorised & Regulated
by the Financial
Service Authority
Firm Number: 300031

Annual Travel Insurance Quote

Quotes emailed to you within minutes (during office hours)

Please fill as much information as possible on the form below to enable us to find the ideal policy.

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Contact Details
First Name(s)
Surname
Date of Birth
Full Address
Postcode
Email Address
Telephone Number
Cover Details
Area of Travel
Definitions	UK - England, Scotland, Wales and Northern Island incl. Isle of Man Europe - Europe, Channel Islands, Republic of Ireland, Madeira, Canary Islands, Syris, Tunisia, Turkey, Egypt, Israel and countries bordering the Mediterranean Sea.
Maximum length of any one Trip
Is baggage cover required?
Do you require Winter Sports Extension?
If you require more than 17 days Winter Sports Cover please specify number of days
Do you require any cover for hazardous activities ?
If yes, please provide full details

Details of additional travellers to be insured

Traveller 2
Sex
Full Name
Date of Birth
Traveller 3
Sex
Full Name
Date of Birth
Relationship to Traveller 1
Traveller 4
Sex
Full Name
Date of Birth
Relationship to Traveller 1
Traveller 5
Sex
Full Name
Date of Birth
Relationship to Traveller 1
Traveller 6
Sex
Full Name
Date of Birth
Relationship to Traveller 1
Traveller 7
Sex
Full Name
Date of Birth
Relationship to Traveller 1

Medical Conditions

Please give FULL details below of any medical conditions for any of the people travelling

Additional Information
Please add any information you feel may affect the quotation.

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