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TRAVEL INSURANCE

International Sport & Leisure act as an Introducer Appointed Representative for the purposes of your travel insurance, appointed by Global Travel Insurance Services Ltd who are authorized and regulated by the Financial Services Authority whose status can be checked on the FSA Register by visiting www.fsa.gov.uk/register or by contacting the FSA on 0845 606 1234. Address for correspondence: Amelia House, Crescent Road, WORTHING, West Sussex, BN11 1RL Telephone: 01903 203933 Fax: 01903 211106 Email ISL09@globaltravelinsurance.co.uk Please use this application form to arrange the insurance described in full in our brochure and on our website. If preferred, you can obtain a quotation and arrange this insurance online via our website by clicking on the weblink provided. Beyond providing this information, we are not allowed to assist you in any way in the arrangement of your travel insurance or give any advice.

Application Form

Please FULLY complete the following in BLOCK CAPITALS. Once complete, return the application panel direct to Global Travel Insurance with a cheque or with card details entered. Insurance is not effective until a Policy has been issued. Please allow at least 5 days before you need to travel. Details of the Applicant

Title Mr/Mrs/Miss)………..….Initials………….…Surname……………………………………….……………………….

House Number/Name……………………….Street Name…………………………………………………………………

Town Name…………………………………..Postcode……………………………..Telephone No. …….……………..

Date of leaving Home………………………………………Date of arrival Home………………………………………..

Geographical Area - See Premium Panel ………………………………………………………………………………...

Booking Reference

Names of all persons to be insured

Age

Premium

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

£

TOTAL PREMIUM

£

Credit/Debit Card Details

Card No

Start Date

Security Code

Issue No

Expiry Date

DECLARATION

On behalf of all persons listed in this application, I agree that this application shall be the basis of the Contact of Insurance. I agree that Insurers may exchange information with other Insurers or their agents. I have read and understood the terms and conditions of the insurance, with which all persons above are in agreement and for whom I am authorized to sign. The form MUST be signed by one of the persons to be insured on behalf of all persons to be insured.

Signed.......................…………………………………………………………………... Date………………………..……

draft IAR

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