Travel - Motts Godwin Insurance Services

Travel Quotation Form

Important Information

Our forms are designed to capture the information upon which a contract of insurance will be based. In order to provide a full quotation and/or issue cover we may require further information or the completion of a full proposal form.

All information you provide must be true and correct to the best of your knowledge and belief. Any information that is likely to influence insurers in the assessment or acceptance of an application should be disclosed prior to the inception of any policy. If you are in any doubt as to whether a fact is relevant you must disclose it.

It may not be possible to quote in all circumstances.

Personal information

Contact Name *
Customer ref.
E-mail *
Main Tel. No
Alternative Contact(s)

Insurance information

Subject/Type of Insurance
Cover Start Date(s)
Target Premium
Existing Insurer
Message *

Travel Details

Area of Travel The definition of the various areas differs from insurer to insurer - especially in the case of ‘Europe’. Please check before arranging cover that your destination is covered correctly. Should you have any queries at this stage, please use the message box below to provide any relevant information.
Insured Category

Age	Number of Travellers
Total Number of Travellers
Infants (0-3 years)
Children (4-17 years)
Adult(s) (18-23 years)
Adult(s) (24-50 years)
Adult(s) (51-64 years)
Adult(s) (65-70 years)
Adult(s) (71-75 years)
Adult(s) (76-85 years)

Main traveller age
Residence of Travellers To be eligible for this insurance, you and all persons to be insured, must be United Kingdom, Channel Islands or Isle of Man resident(s) with a home there or have resided there for at least 6 months out of the last 12 months and have a permanent address in the United Kingdom, Channel Islands or Isle of Man.

Medical Conditions

Click here if you have no medical condition(s) to declare.
Click here if you, or any person to be insured or person on whom the trip depends have any pre-existing medical condition(s) to declare.
Please note that you may be required to contact a medical screening service once a quotation has been provided to validate the quotation. If applicable, please use the Message or Extra Information boxes to give any details you feel may help us at this stage.

Extra

Please use this space for any additional claims or information for which there was not room elsewhere.

Please remember that you must inform insurers of any circumstances of which they may not be aware. Failure to do so could invalidate a policy. If you are in any doubt as to whether a fact is material it should be disclosed.

Whilst not required for an initial quick enquiry, these fields may help speed our response.

Type of Insured? Individual Company
- Firm/Company/Trust Name
- Policyholder Date of Birth
- Occupation
- Marital Status
Source of introduction
Contact Address
Contact Post Code

* Required Field

Forms may make various assumptions in terms of the default answers to questions. Please ensure that you have checked all fields before submitting your information for quotation.
When you complete this form you are declaring that the information given is true and complete and that no relevant information has been withheld or omitted. You are also declaring that you understand the contents of this completed application including the important information at the start of the form.
You should keep a record of all information supplied to us for the purpose of this application

You should keep a record (including copies of letters) of all information supplied to us for the purposes of this insurance.

Call 0208 444 1040