Allcare Insurance Agency Ltd
University Roundabout
Msida MSD 1751 Malta
Tel:
(356) 21 330011
Fax:
(356) 21 347947/8
TRAVEL INSURANCE QUOTATION FORM
Name
*
Address for Correspondence
Postcode
Tel. No. / Mobile No. :
*
Fax. No.
E-mail Address
*
Name of first applicant
ID No.
Age*
Cover
Additional Limit Lm
Budget
Economy
Club
Name of other applicants
ID No.
Age*
Cover
Additional Limit Lm
Budget
Economy
Club
Budget
Economy
Club
Budget
Economy
Club
Budget
Economy
Club
Budget
Economy
Club
Territorial Limits
Area 1
Area 2
Area 3
Tick box if WINTER SPORTS cover is required
Duration of Holiday
(Maximum Period of 90 Days)
Days From
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2007
2008
2009
2010
2011
2012
2013
Should you require any further information do not hesitate to contact us for a customised quote
DATA PROTECTION
Insofar as the information that you provide us with in this form constitutes personal data for the purposes of the Data Protection Act 2001, Allcare Insurance Agency Limited will only process this information in the manner and for the purposes laid down in its Privacy Policy. By completing this form and clicking on the ‘Submit’ button below, you consent to Allcare Insurance Agency Limited processing this information in accordance with this Policy. Please view our
Privacy Policy
before submitting this form.
