Travel Insurance Form

Please Answer The Following Questions:
1. Have you ever been diagnosed or received any treatment (including hospital or surgery) or felt any disorder or pain or had any symptoms indicating: heart disease, high blood pressure, congenital diseases or deformities, cancer, nervous or mental disorders, AIDS, back problems.

2. Do you have any physical disability or impalement.

3. Are you involved or planning to be involved in a dangerous sport or hobby.

* N.B: If the answer to any of the above question is (yes) please give details hereunder:

To the best of my knowledge, the answers given in this proposal, are true and complete and I fully understand and agree that if the Insurer accepts my Application, it shall form the basis of the proposed policy and the insurance cover shall only commence as from the date mentioned in the issued policy.