Travel Insurance form

Applying for or enquiring about travel insurance.

If you would like to apply for travel insurance on the basis outlined by Wisemans in the laterlife travel insurance section, then please complete and submit the form below which will be routed to Wisemans. Wisemans will then prepare your policy and phone you to confirm and collect the premium. You can pay by credit card over the phone or mail your cheque to Wisemans (address below).

If you fall outside the age limits for the policy shown in the laterlife travel insurance section, please complete the enquiry form anyway providing age information in the additional comments field. Wisemans will then provide a quotation from alternative insurers.

Please note that we endeavour to ensure all prices and cover details quoted on the laterlife.com site are up to date, but these are subject to final confirmation with Wisemans. All cover is subject to the full Terms & Conditions of the Fortis Travel policy, a full copy of which is issued with your insurance certificate or is available on request.

Please note that laterlife.com is not itself involved in making any recommendation as to the suitability of a particular policy.

If you have a query prior to applying, then please phone Yvonne Watts or Lee Fuller at Wisemans on 01784 242138 quoting that your call relates to laterlife travel insurance.

It is a condition of applying for this insurance that you have read and are able to make the declaration at the foot of this page.

Please do not include any details of credit cards when submitting the information below.

Applications can only be dealt with from UK based applicants.

Please ensure that you enter all details requested to enable Wisemans to process your application and to enable them to contact you. If anything is unclear please use the 'additional comments' field to provide information or raise a query.

Wisemans Media Code:

I confirm that I have read and I am able to make the declaration at the foot of this page:

Title:

First Name:

Last name:

Your Email Address:

Single trip or Multi-trip insurance:

Geographical Limits (UK, EU, XU, WW). See definitions on prices page:

Commencement date (only required if later than standard or for single trips with no cancellation cover):

Commencement date is normally
date of premium payment.

Trip Duration:

Please select the appropriate options to indicate the number of people to be included e.g. if applying for family cover don't include children separately:

Please note definitions of Child, Couple and Family on Details and Prices page.

Couples (under 65)	Family (2 adults under 65)	Children under 18 at departure date

Adults under 65	Infants under 2 at departure date

Adults 65-79 (single trip)

Names of travellers:

Please include names of all those to be covered and their Date of Birth.

Do you want to include the winter sports option?

Do you want to include or exclude personal belongings cover?

Do you want to include or exclude cancellation cover?

Do you want to include the business equipment option?

Your Contact Telephone Number (Day):

Essential

Alternative Telephone Number (if any):

Home Address:

Post code (this is essential for tracking purposes):

Additional Comments:

Would you like to receive Yes No Already receive
the monthly laterlife.com
email newsletter
(you can unsubscribe at any time)

The newsletter provides updates on laterlife.com, including new articles, offers and competitions.

Wisemans Media Code:

Please ensure you have completed both Telephone & email fields before submitting so that we can contact you.


Declaration
The Compass Travel Insurance policy contains health restrictions. You must be able to make the following declaration for yourself and each insured person. For you and each insured person As far as I know the following apply:
a	Nobody is waiting for an operation, hospital consultation (other than for regular check ups), or other hospital treatment or investigations.
b	Nobody has received treatment, other than regular medication, in the last 12 months for:
	any blood disorder any form of cancer, leukaemia or tumour a transplant	any psychiatric illness dialysis treatment; or dementia
c	Nobody, diagnosed as HIV positive, has required treatment for HIV or any HIV related illness
d	Nobody has any breathing or heart problem which has needed hospital treatment in the last 12 months
e	Nobody has been seen by a specialist in the last 3 months (other than for regular check ups) or been admitted to a hospital overnight
f	Nobody has been given a terminal prognosis by a registered doctor.
g	I do not know of any reason (medical or otherwise) why the trip is likely to be cancelled or cut short)
	If you or anyone travelling with you cannot agree with this declaration when you take out the insurance, you must phone the Fortis Health line on 08701 222038 quoting scheme code CT1. You must do this when you take out this insurance and they will tell you if they can give you cover. If you cannot contact them when you buy this insurance, you must contact them within 14 days (but before you travel). They will tell you if they need any more information.
	If there is a change in your medical condition or the medical condition of anyone travelling with you (after you have taken out this insurance, but before you travel) and you can no longer agree with the declaration, you must contact the Fortis Health Line immediately on 08701 222038 quoting scheme code CT1. They will tell you if cover can continue. If we cannot continue cover, you may claim for the cost of cancelling at that time.
For annual multi-trip cover, you must agree with this declaration each time you book a trip. For a close relative or business associate or anyone else who is not an insured person and whose health may affect the trip. If at the time of taking out this insurance, (or booking the trip if this was later) your close relative or business associate had a medical condition for which they: were receiving treatment at hospital were waiting for a hospital consultation or treatment had been given a terminal prognosis or been told that their condition is likely to get worse in the next 12 months; we will not pay for any problem which has anything to do with that medical condition.
Important I have read the declaration and as far as I know I can agree with the statements above. If I have not been able to agree with all the statements contained in the declaration above, I have contacted the Fortis Health Line who have accepted cover and given me a reference number.
Wisemans Independent Insurance Advisers 34, Church Road Ashford Middlesex TW15 2UY

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