Blue Water Rallies Travel Application Form

Travel Insurance designed to meet the requirements of Owners and Crewmen participating in the 2009 Blue Water World Cruising Rally. Arranged by G.H. Insurance Services Limited Underwritten by Canopius Underwriting Ltd on behalf of Syndicate 4444 at Lloyd's.

PREMIUM for full 20 month period:

Principle Insured person £ 800
Spouse or partner £ 720
Individual Crew: at principle Insured Premium as above
Extensions available (see the travel benefits PDF):
- Cancellation loss of deposit & pound;285 plus £ 50 per additional crew
- Rejoining the rally £ 175

All amounts inclusive of 17.5% insurance premium tax

Please fill in the form below.

* Required fields

PRINCIPAL INSURED

* First Name:

* Surname:

* Date of Birth:

* Nationality

* Address:

* Postcode:

* Telephone:

Fax

* Email address:

Do you require travel insurance prior to the rally? If so please state date you require insurance to commence:

Are you participating in the entire Rally?

Yes
No

If No, please advise dates and we shall advise you of the premium required.

Outward date:

Return date:

Outward date:

Return date:

OTHER PERSONS TO BE INSURED

First Name:

Surname:

Date of Birth:

First Name:

Surname:

Date of Birth:

First Name:

Surname:

Date of Birth:

First Name:

Surname:

Date of Birth:

IMPORTANT NOTICE: PLEASE READ THE FOLLOWING

You may find it helpful to keep an independent record of the information you supply in connection with your proposal, including copies of any relevant letters. A copy of your completed Proposal Form is available from your Insurance Broker on request within three months of completion. Any enquiry or complaint concerning this Insurance should in the first instance be addressed to your Insurance Broker. If you are not satisfied with the manner in which your complaint has been dealt, you may ask the Complaints Department at Lloyd’s of London to review your case without prejudice to your rights in law. The address is: Complaints Department, Lloyd’s of London, One Lime Street, London, EC3M 7HA. Telephone (020) 7327 5693.Cooling Off period, if within 14 days of accepting this insurance, you discover that it is unsuitable, your unused premium will be refunded to you at short-term rates, provided that you have not made a claim. I consent to the Underwriters seeking medical information concerning anything that affects my physical or mental health and seeking any information from any Insurance Office to which a proposal has been made for insurance on my life and I authorise the giving of such information. I hereby consent to any information you may have about me being processed by you for the purposes of providing insurance and claims handling, which may necessitate your providing such information to third parties.

This insurance excludes trips booked or commenced against medical advice or after receipt of a terminal prognosis or for the purpose of obtaining medical treatment or convalescent care. It also excludes claims for medical conditions or other circumstances known to the Insured Person at the time that the trip was booked or the insurance was effected whichever was the later. If at any time you are in doubt about the relevance of these or any other exclusions mentioned herein, clarification should be sought from underwriters.

Please state:

Dates:
Nature of Ailment:
Treatment Received: (If none, state NONE)

Upon receipt of application we will write enclosing our premium demand note. Please note completion of this application form does not constitute evidence that cover is in force. Insuring document will be provided after receipt of the payment of the premium due.