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Sales Contact
Has a member of our sales team contacted you?
Yes
No
If Yes:
Which of our sales executives were you dealing with?
Select Sales Executive
Rowan Devereux
Paul Downing
Elaine Jones
Suzanne Mulfaul
Ciaran Mulligan
Maeve Slamon
Jason Whelan
None
Approximately when were you speaking with them last?
Select Period
This Week
Last Week
2 Weeks Ago
3 Weeks Ago
4 Weeks Ago
Over 1 Month Ago
Company Details
Select Consortium
None
NAITA (Advantage)
Worldchoice
Midconsort
SWIFTA
SCOTW
Travel Trade
Global Travel
Other (please state)
Insurance Details
Net annual insurance turnover *
Projected annual Insurance turnover *
Period (Years) *
Years
-
1
2
3
4
5
6
7
8
9
10+
Current Renewal Date *
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
2025
2026
2027
Type of Business (%)
Late Bookings (less than 4 weeks)
Tailor-made
Flight Only
Cruise
Package
Business Travel
Weekend Break
Other
Business Split (%)
Europe
Worldwide (Excl USA)
Worldwide (Incl USA)
Type of Policy (%)
Single Trip
Annual
Backpack / Longstay
Client Age Band (%)
Under 66
70-80
66-69
81+
Current Underwriter
Special Requests
Declaration/Confirmation
Please double check the entries you have made above, once you are happy please check the box, you will then be able to submit your application.
I hereby confirm the above to be a true, accurate and valid assessment of my Insurance needs.
Please enter the text you see on the right