Travel Insurance for Women

Application form - Couple Please note this cover is only available to people under 65. People over 65 can call our helpline - 0800 0151800 quoting diabeticlife.co.uk between the hours of 8am till 6pm monday to friday. This policy is a annual multi trip policy which covers you for 31 days per trip. Single | Couple | Single Parent | Family
Title	Applicant 1
First Name	Applicant 1
Surname	Applicant 1
Date of Birth	Applicant 1
Title	Applicant 2
First Name	Applicant 2
Surname	Applicant 2
Date of Birth	Applicant 2
Address
Postcode
Email
Daytime Telephone (Compulsory)
Once your case has been accepted by our underwriters, the travel specialists will give you a call and confirm that you have been accepted and if you wish to proceed will then request your credit card details for payment of the annual premium.
When was the condition first diagnosed?
What is your holiday/trip destination?
Policy Start Date
	Yes	No
1. Is the Diabetes stable?
2. Is it controlled by tablets/insulin?
If you have answered No to either questions 1 or 2, or if you have more than 1 medical condition, then further medical information will be requested.
3. Have you been hospitalised in the last 12 months as a result of this condition?
4. Do you have any of the following conditions?
Skin problems?
Kidney problems?
Blood vessel/cardiac problems?
Eye problems?
Nerve problems?
Comments
If you have answered Yes to either question 3 or any part of question 4, or if you have more than 1 medical condition, then further medical information will be requested.
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Important Completion of this application does not automatically guarantee cover. A representative will call you within 24 hours of receipt of this form to confirm whether you are eligible for cover. Data Protection Your information (including information we already hold and may receive now and in the future as well as information about lapsed policies) may be held on a group database and may be shared with other MMC group companies. Your information will be used for general insurance administration purposes, for offering renewal, for research and statistical purposes and for crime prevention. In the course of perfomring our obligations to you, your information may be disclosed to agents and service providers appointed by us, including insurers, consultants, market research and quality assurance companies. Your information may be transferred to any country including countries outside the European Economic Area for any of these purposes and for systems administration. Such information may include 'sensitive data'. The Data Protection Act 1998 defines sensitive data as information about your racial or ethical origin, political opinions, religious beliefs or beliefs of a similar nature, trade union membership, physical condition or mental health, sexual life, criminal record, pending course proceedings or sentence or any alleded offence. You have the right to access (subject to limited exceptions) and if necessary rectify the information that we hold about you. We may use your information to keep you informed by post, telephone, e-mail or other means about products and services which we feel will be of interest to you. This may include products and services offered by other businesses approved by us and to whom we have disclosed your information to enable them to contact you direct. Your information may be disclosed and used for these purposes after your policy has lapsed. If you do not wish your information to be used for these marketing purposes please write to: Customer Services Manager, Medisure Affinity Services Ltd, 100 Temple Street, Bristol, BS1 6EN. Warning To the best of your knowledge and belief, the information given in this Application must be true and complete.