Travel Insurance Quote Name Address Post Code eMail Telephone Mobile Person to contact Best time for contact? Destination of travel Date of outward travel Return date of travel APPLICANTS Names Date of Birth Medical conditions to declare Yes   No Yes   No Yes   No Yes   No Yes   No Details of Medical Conditions to declare: Names Condition History Medication Do you wish to exclude baggage insurance, as you can confirm that cover is already insured under your own House contents insurance? Yes   No Do you wish to exclude cover in respect of cancellation or curtailment of your trip? Yes   No Do you wish to include cover for Winter sports? Yes   No Are you interested in a quotation for annual travel insurance? Yes   No Comments   WHITE KNIGHT GROUP Britannia House High Street Bream, Lydney Glos GL15 6JS Tel 01594 563288 Fax 01594 564084 Email janeclark@whiteknightgroup.co.uk FSA number is 121356 White Knight Group is an independent intermediary authorised and regulated by The Financial Services Authority who also trade under the names of Dean Magna Insurance & Financial Consultants, Farmer & Clark Insurance & Financial Consultants and Swambo Woollett Insurance & Financial Consultants. Please refer to www.fsa.gov.uk for further information.

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