TRAVEL INSURANCE FORM     Please fill out the form below and we will find the best premium for you. We can offer a discount of 10% to 25% off on all policies.

	Main Destination		Please select main destination USA (America) Africa Bali/ Indonesia Europe Japan New Zealand South East Asia South West Pacific United Kingdom
			NOTE: 6 months maximum for Bali / Indonesia and South West Pacific
	Duration of Travel		Indicate length of stay 5 days 8 days 12 days 16 days 24 days 28 days 34 days 42 days 49 days 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 12 months
	Type of Policy		Please choose type of policy Single Duo Family Frequent Traveller: Annual Policy
	Date of Departure		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 APRIL MAY JUNE JULY AUG SEPT OCT NOV DEC Year 2006 2007 2008 2009 2010 2011 2012 2013 2015
	City/Airport of Departure (from Australia only)		Indicate which Australian airport Melbourne Adelaide Brisbane Sydney Canberra Perth Hobart
	Full Cover (under 70 years of age)		Cancellation/ Medical and additional expenses/ Baggage including travel documents and emergency baggage/ Resumption of journey/ Personal Liability/ Accidental Death and Loss of Income/ Travel Delay/ Rental vehicle insurance excess/ Cash in hospital.
	Selective Options		Medical & Baggage
	(Maximum 3 months for under 60 years of age)		Medical & Cancellation
			Medical / Baggage / Cancellation
	Your Name
	Your email address
			If you wish to be contacted by phone please type your phone no.