Country of Registration: Tools, Spare Parts & Licence Accessories in GBP: £ (of Home Country) (If insurance is required) What, if any, is the difference between the normal market value of your car type and the version you have prepared for the event? £ Please state details of any losses(including theft), whether insured or not in last 3 years for each Claims History driver including dates and costs for own damage/third party damage explaining circumstances – use a separate sheet if necessary. IF NONE, STATE NONE: Driver 1: Driver 2: Conviction History Please state any driving convictions for each driver, i.e, speeding, careless driving, drink/drug related offences etc. together with relevant fines / licence endorsements sustained within the last 5 years. IF NONE, STATE NONE: Driver 1: Driver 2: Please complete supplementary page provided for additional drivers / further details Travel Insurance/ Repatriation Declaration Have/are you or anyone to be insured on this policy 1. suffered from or received any ongoing treatment for any heart or cancer condition in the last five years? Yes No 2. currently receiving or have you received in the last 12 months, any advice, medication or treatment for any illness, injury or disease? Yes No 3. investigation or awaiting results for any diagnosed or undiagnosed medical condition? Yes No 4. travelling against your doctor’s advice, or for the purpose of obtaining treatment? Yes No 5. received a terminal prognosis? Yes No 6. on a waiting list for, or aware of the need for, any in-patient treatment? Yes No If you answered yes to any of the questions please provide further details below, stating which driver it applies too:
Country of Registration: Tools, Spare Parts & Accessories in GBP: £ Licence (of Home Country) (If insurance is required) What, if any, is the difference between the normal market value of your car type and the version you have prepared for the event? £ Claims History Please state details of any losses(including theft), whether insured or not in last 3 years for each driver including dates and costs for own damage/third party damage explaining circumstances – use a separate sheet if necessary. IF NONE, STATE NONE: Driver 1: Driver 2: Conviction History Please state any driving convictions for each driver, i.e, speeding, careless driving, drink/drug related offences etc. together with relevant fines / licence endorsements sustained within the last 5 years. IF NONE, STATE NONE: Driver 1: Driver 2: Please complete supplementary page provided for additional drivers / further details Travel Insurance/ Repatriation Declaration Have/are you or anyone to be insured on this policy 1. suffered from or received any ongoing treatment for any heart or cancer condition in the last five years? Yes No 2. currently receiving or have you received in the last 12 months, any advice, medication or treatment for any illness, injury or disease? Yes No 3. investigation or awaiting results for any diagnosed or undiagnosed medical condition? Yes No 4. travelling against your doctor’s advice, or for the purpose of obtaining treatment? Yes No 5. received a terminal prognosis? Yes No 6. on a waiting list for, or aware of the need for, any in-patient treatment? Yes No If you answered yes to any of the questions please provide further details below, stating which driver it applies too:
Application-Form-Africa-1.docx