Allcare Insurance Agency Ltd University Roundabout
Msida MSD 1751 Malta

Tel: (356) 21 330011
Fax: (356) 21 347947/8

 

  Name of Applicant *
Date of Birth *
ID Card No.*
Cover *
Premium € (Refer to premium rates) *
 
Address of Applicant *        
Email* Telephone*
Name of Other Applicants (in case of children write NA in ID No. field)
Date of Birth
ID No.
Cover
Premium € (Refer to premium rates)
Additional Limits (Refer to Important Notes)
Additional Limit €
Additional Premium €
Increase Accidental Death / Permanent Total Disablement
Increase Baggage or Money Cover
Increase in the limits for any one article
Winter Sports
Destination Territorial Limits: Area (Refer to territorial limits) *
Duration of holiday
(Maximum period of 90 days)
1 *
for
 days *
2  
From* 
3  
To* 
Do any of the applicants to be insured suffer from any medical condition? Yes No
Please refer to Health Warranty*
(If yes please provide details):
 


* Health Warranty
If you cannot guarantee any of the statements listed under the following Health Warranty, you must advise us immediately.  Failure to do so could invalidate your policy.  It is important, as it may affect your cover, that you should tell us at the time of purchasing or renewing your policy or when booking a trip (whichever is later), if you or any insured person:

  1. Have received advice, medication or treatment for any serious chronic or recurring illness, injury or disease in the last 12 months.
  2. Are under investigation or awaiting the results of any diagnosed or undiagnosed medical condition.
  3. Are on a waiting list for, or are aware of the need for, in-patient treatment for any diagnosed or undiagnosed medical condition.
  4. Are traveling against your doctor’s advice.
  5. Any close relative, close business associate, traveling companion, or person with whom you plan to stay (and upon whose good health your trip depends) has a serious, chronic or recurring illness, injury or disease which could affect your decision to take or continue your trip.
  6. Have received a terminal prognosis.
I/We declare that the information given in this proposal is to the best of my/our knowledge correct and complete in every detail.  Further I/we agree that if my/our answer has been written by any other person on my/our behalf, such person shall for that purpose be regarded as my/our Agent and not the Agent of Middlesea Insurance.  When completing this application, you should disclose any fact which may influence the acceptance of the risk.
 
I confirm having read the provisions contained in the Health Warranty *
 

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.
 

ALLCARE INSURANCE AGENCY LTD are not on risk before this proposal is accepted by underwriters and a written confirmation to this effect is submitted