ONLINE APPLICATION FOR ATLAS TRAVEL INSURANCE COVER


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. 

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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
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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
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.