Travel Insurance - Long Stay
Tel: 01992 718666
To obtain a quote, please complete the following, and press the "Submit Request" button at the bottom of the form. We will contact you by telephone or email with a quote.
email Address
Confirm email Address
Title
Mr.
Mrs.
Miss.
Ms.
Dr.
Other
First Name
Surname
House No./Name
Street
Town
County
Post Code
Country
UK
Tel. Number - Day.
Tel Number - Evening
Occupation
Age
Where Did You See Us Advertised
Existing Customer (Any Product)
YES
NO
Date of Travel
Duration of stay
Destination
Europe
Worldwide inc. USA
USA
Names & Ages of Additional Insured Persons
Additional Information
Declaration:
I declare that the information I have given above is true and complete. I have not withheld any material facts (see
IMPORTANT NOTES
.) I agree that this proposal shall form the basis of the Contract between me and Shearwater Insurance.
Shearwater Insurance Services Ltd
Registered Office: 2 Bath Place, London, EC2A 3JJ. Registered in the UK Company No: 02701633
