Travel Insurance

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Please fill-in following form

Information about the subscriber

- Title


First name (required)


Last name (required)

Your Email (required)


Telephone (required)

Town of residence (required)


Country of residence (required)

Date of birth (required) format yyyy/mm/dd


Profession (required)

Other persons to cover

Are you married?

Please complete if you DO want to cover your wife/partner

Do you want to cover your wife/partner?


Date of birth partner/wife format dd/mm/yyyy

Have you got children?

If you want to cover also your children, please specify dates of birth (if more than 3 children, contact us directly).

- Date of birth child #1 dd/mm/yyyy


Date of birth child #2 dd/mm/yyyy


Date of birth child #3 dd/mm/yyyy

Information about the trips

Your trips are for:

Value of your trip (in euro)

Are you seeking for annual or temporary cover? (NOTE : we cannot incept cover if trip in more than 60 days, we can only provide quote which may change)

-If temporary then travelling from :


To :

Territorial limits :


Select your coverage options ( required) :

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Please send me a free, no obligation, quotation based on the above :