TRAVEL INSURANCE QUESTIONNAIRE | East Ivanhoe Travel & Cruise

This form is to assist your Consultant in Quoting. Further information and assessments may be required directly with the Insurance Provider

CRUISING - Are any travellers travelling for 2 or more nights on a cruise on the sea or ocean, or on a river outside of Australia?

YES
NO

LUGGAGE - Do any travellers require additional luggage cover?

YES
NO

SNOW SPORTS - Do any travellers require cover for snow skiing, snowboarding or snowmobiling?

YES
NO

MOTORCYCLE/SCOOTER - Do any travellers require cover for driving or riding a Motorcycle/Scooter? (strict conditions apply)

YES
NO

ADVENTURE ACTIVITIES- Do any travellers require cover for Adventure Activites? (eg Rock Climbing, Triathlon, Scuba, SkyDiving, Trekking?)

YES
NO

EXISTING MEDICAL CONDITIONS - Please tick any below that apply and use the comments box at the end of this form for any further information.

In the last 12 months, has any traveller been hospitalised or treated in the emergency department, seen a specialist, or had day surgery?

*

Has any traveller got a chronic, ongoing or reoccurring condition? e.g. arthritis or back pain

*

Is any traveller experiencing any signs or symptoms where a medical diagnosis has not been sought? e.g. chest pain, shortness of breath, a persistent cough or unexplained bleeding.

*

Is any traveller taking prescription or over the counter medication to treat, control or prevent their condition?

e.g. insulin for diabetes, aspirin for strokes, Paracetamol for back pain , having regular check-ups? or under investigation, waiting on a diagnosis or surgery?

*

Has any traveller ever had a medical condition or required surgery involving any of the following?

Kidneys, Liver / Cancer (even if in remission) / Joint, back or spine / Brain e.g. Dementia, Epilepsy, head injury, Tumours / Any heart-related condition e.g. Angina, bypass surgery, heart attack, irregular heart rhythms, stents / Strokes e.g. clots, Deep Vein Thrombosis, mini strokes, Pulmonary Embolism / Respiratory system e.g. Chronic Bronchitis, COPD, Emphysema

*

If any travellers are pregnant

Have there been complications with this or a previous pregnancy? / Is it a multiple pregnancy e.g.twins or triplets ? / Was the conception medically assisted? e.g. using assisted fertility treatment including hormone therapies or IVF ?(Pregnancy cover is limited to unexpected complications up to the 24th week. Childbirth or care of a newborn is not covered)

DECLARATION/S

*

I understand my Consultant can only offer General Advice and I confirm I have taken reasonable care not to make a misrepresentation, including the consequences of making a misrepresentation.

*

My answers to the above questionnaire are true and I have taken reasonable care not to make a misrepresentation when answering the questions

*

I have recieved the Combined FSG/PDS (hard copy or email) and are aware of current Travel Advice for my destination/s

*

I have been advised of all the options available to vary the cover on this policy and confirm that the options selected have been selected by me

Please add any comments/notes for your Advisor,

Your Personal & Medical Information is confidential between you and your Consultant. We may need to disclose this information with the insuerer and/or Travel Provider with your permisson.

Completed by (name) *

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