Individual Travel Insurance Proposal Form

* The United Kingdom, Andorra, Austria, Belarus, Belgium, Bosnia-Herzegovina, Bulgaria, Canary Islands, Channel Islands, Croatia, Czech Republic, Denmark, Estonia, Finland, Faroe Islands, France, Germany, Greece, Hungary, Iceland, Isle of Man, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Macedonia, Madeira, Mediterranean Islands (including Majorca, Menorca, Ibiza, Corsica, Sardinia, Sicily, Malta, Gozo; Crete, Rhodes and other Greek Islands, Northern and Southern Cyprus), Moldova, Monaco, Morocco, Netherlands, Norway (excluding Svalbard), Poland, Portugal, Republic of Ireland, Romania, Russian Federation (West of Urals), Serbia and Montenegro, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tunisia, Turkey and the Ukraine (Albania, although in Europe, is excluded. If you wish to visit Albania or are likely to travel outside the countries specified you need to buy cover for travel Worldwide or Worldwide excluding USA, Canada & the Caribbean).

To enable us to provide a quotation, please detail the number of people to be covered in the age bands below:

To Be Eligible For Cover You Must Be Medically Fit To Travel: a) on the date of purchasing this Policy; and b) booking any Trip; and c) on the date(s) You pay any further instalments or final balance; and d) on the date of departure of the Trip. Being medically fit to travel means: 1. any existing Medical Condition(s) You have must be stable and controlled by any treatment You are receiving and/or medication(s) you have been prescribed; and 2. there must be no known likelihood of any specific treatment or variation of medication for any existing Medical Condition(s) on any of the above dates, or whilst travelling; and 3. You are not exhibiting symptoms of an existing Medical Condition which could mean that Your Trip could be cancelled or cut short. It is always advisable to consult a Medical Practitioner if You have any doubts about whether You are medically fit to undertake a Trip.

following any claim investigation, Your Medical Practitioner confirms You were not fit to undertake Your travel plans on the date of purchasing this Policy, booking any Trip or on the date of departure of Your Trip (whichever is later). • You know You will need medical treatment or a consultation at a medical facility during Your Trip. You are travelling specifically for the purpose of having surgery, medical procedures or Hospital treatment, whether medically necessary or not. • You had been diagnosed with a terminal illness prior to the date of purchasing this Policy or booking Your Trip (whichever is later). • You are affected by any Medical Condition that You are aware of, that could reasonably be expected to result in a claim on this Policy. • You are aware of a Medical Condition for which You have not had a diagnosis. • You travel against any health requirements stipulated by the carrier, their handling agents or any other Public Transport provider.

(other than for regular check ups for a stable well controlled condition) or other Hospital treatment for a diagnosed condition. You will NOT be covered for any claims directly or indirectly related under: Section 1 - Cancellation or Curtailment Charges, Section 2 - Emergency Medical & Other Expenses, Section 3 - Hospital Inconvenience Benefit and Section 4 - Personal Accident

e.g. hay fever, tonsillitis, ear infections, colds / flu, skin irritations, chiropody, dental treatment etc. provided You: • were only prescribed short term antibiotics, non-prescription pain killers, creams/ointments; • have had no further problems since; or • have been advised by Your Medical Practitioner that it is safe to travel. Note: This is not a private medical insurance Policy and only gives cover for emergency medical treatment in the event of accident or unexpected illness occurring during Your Trip.

I / We confirm that the statements and particulars contained in this form are true and complete. I / We will provide details of any alteration to this information as soon as possible prior to commencement of the Period of Insurance. I / We have read and understood the Important Exclusions Relating to Your Health. I / We confirm that all persons to be insured are: • a member of the British Caving Association (BCA) or a member of an affiliated club or family of a member who is also covered under this insurance; • permanently resident in the United Kingdom, the Channel Islands or the Isle of Man at the time of purchasing this insurance; • registered with a Medical Practitioner in the United Kingdom, the Channel Islands or the Isle of Man; I / We confirm that the trip starts and ends in the United Kingdom, the Channel Islands or the Isle of Man or from an HM Base or British Embassy.