Group Business Travel Insurance Plan

Name of Broker / Intermediary / Agent

Broker's Address

Broker's Post Code

Broker's Telephone Number

Broker's Fax Number

Broker's Email Address

Name of Proposer

Occupation

Type/s of Work Undertaken by Employee/s to be Insured

Number of Employee/s to be Insured

Please Give Details of Any Manual Work to be Carried Out

Business Travel Pattern

Europe
Number of Trips

Average Duration

USA/Canada
Number of Trips

Average Duration

Elsewhere
Number of Trips

Average Duration

Is cover to be extended to include Business trips within the United Kingdom where Air travel or an overnight stay away from home is involved? If so please state.

Number of Trips

Average Duration

Is cover to be extended to include personal holiday travel? If so please provide details of separate travel arrangements/pattern:

Number of Trips

Average Duration

Do you wish cover to be extended to include Holiday Travel?

If so please confirm number of specified employees requiring cover

Do you wish cover to be extended to include Holiday Trips by Employee Spouse/Partner and Children?

If so please state number of persons requiring this extension