Name

Email Address

Phone Number

Excess
---$0$150$250

Cancellation Cover---$0$6000$10000$20000$30000$40000$60000$80000Unlimited

Type of Policy
---LeisureBusinessCruiseGroup

Area of Travel
---WorldwideEuropeAsiaMiddle EastSouth East AsiaUKIndonesiaSouth PacificNZAustralia InboundAustralia

Country Most Time Spent

Departure Date

Return Date

Travellers Age

Are all travellers currently living in Australia
---YesNo

Are any travellers travelling for 2 or more nights on a cruise on the sea or ocean, or on a river outside of Australia?
---YesNo

Do any travellers require luggage cover?
---YesNo

Do any travellers require cover for snow skiing, snowboarding or snowmobiling?
---YesNo

Do any travellers require Adventure Activity cover?
---YesNo

Do any travellers require Motorcycle/Moped Riding cover?
---YesNo

In the last 12 months, has any traveller been hospitalised or treated in the emergency department, seen a specialist, or had day surgery?---YesNo

taking prescription or over the counter medication to treat, control or prevent their condition? e.g. insulin for diabetes, aspirin for strokes, Paracetamol for back pain having regular check-ups?
Under investigation, waiting on a diagnosis or surgery?
---YesNo

Has any traveller got a chronic, ongoing or reoccurring condition? e.g. arthritis or back pain
---YesNo

Has any traveller ever had a medical condition or required surgery involving any of the following? Kidneys, Liver Cancer (even if in remission), Joint, back or spine, Brain Dementia, Epilepsy, head injury, Tumours, Any heart-related condition, Angina, bypass surgery, heart attack, irregular heart rhythms, stents, Strokes clots, Deep Vein Thrombosis, mini-strokes, Pulmonary Embolism, Respiratory system Chronic Bronchitis, COPD, Emphysema
---YesNo

If any travellers are pregnant: Have there been complications with this or a previous pregnancy? Is it a multiple pregnancy e.g.twins or triplets ? Was the conception medically assisted? eg using assisted fertility treatment including hormone therapies or IVF (Pregnancy cover is limited to unexpected complications up to the 24th week. Childbirth or care of a newborn is not covered)
---YesNo

Is any traveller experiencing any signs or symptoms where a medical diagnosis has not been sought? eg chest pain, shortness of breath, a persistent cough or unexplained bleeding---YesNo