Travel Insurance Application

Please read this part before proceeding
The sections in RED are compulsory information and must be completed by a member. The member does not have to travel with the person(s) they are insuring, but if you are travelling with them you must add your name to the list of travellers to be insured. Travellers may depart and/or return on different dates. If the travellers require different levels of cover please use separate forms. Maximum cover available for any one journey is 6 months at a time. You may take out a second six months cover following that but the total cover for one journey must not exceed 12 months.

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Member's first Name:		Member's Last Name:
Email address:		Atlas Membership Number:
Select cover type required:		Day Time Phone Contact	area codeNumber
Note	Any travel by sea vessel is international travel
Names of travellers to be insured:
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1. First Name :		Last Name:
Depart Date dd/mm/yy		Return Date dd/mm/yy
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2. First Name:		Last Name:
Depart Date dd/mm/yy		Return Date dd/mm/yy
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3. First Name:		Last Name:
Depart Date dd/mm/yy		Return Date dd/mm/yy
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4. First Name:		Last Name:
Depart Date dd/mm/yy		Return Date dd/mm/yy
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5. First Name:		Last Name:
Depart Date dd/mm/yy		Return Date dd/mm/yy
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6. First Name:		Last Name:
Depart Date dd/mm/yy		Return Date dd/mm/yy
If any of these travellers is under the age of 12 years at time of travel insert their name with a comma in between them		Names ages
Are any of the nominated travellers over the age of 70 years? If so which ones?			Names
If over 70 years please state age or ages
Do any of the proposed travellers have any pre-existing medical conditions?
If yes a brief description of medical condition

Are any of the proposed travellers on prescribed medication?
If yes a brief description of medications
How do you wish to pay your premium?
I acknowledge that I have read the Master policy:

Now submit your application and please wait approximately 60 seconds for a confirmation that it has been received at the server.