All fields must be filled in, thank you. Name Email Company Phone Number   Estimate number of Overseas trips in the next 12 months: Average Duration: Maximum Duration: Estimate number of Local trips in the next 12 months: Average Duration: Maximum Duration: Do you plan to travel to or through hostile countries? Yes No   If so, which countries, for how long and do you require war cover? Estimate number of Charter/Helicopter or Non-Scheduled Flights in the next 12 months: Maximum Number of people travelling together Do you require cover for Electronic Equipment over $1000? Yes No   Description and Replacement value of electronic equipment: Do you require Kidnap & Ransom cover in Mexico, Central & South America?: Yes No   Do You Currently have Corporate Travel Insurance? Yes No   If so, who is the insurer? Claims experience over the last 3 years Base Sum Insured (Check box only, if happy with base figure) Required Sum Insured (Sum insured if different to base) Death and Capital benefits $ 500 000 Weekly Benefits (7 day excess) $1,500 Overseas Medical Expenses $1,000,000 Kidnap and Ransom $250,000 Money Sum Insured $2,500 Loss of Deposits $10,000 Travellers Baggage $10,000 (Limit $ 2,500 any one item) Electronic Equipment $10,000 (limited to $1,000 per item unless specified) Personal Liability $10,000,000 Alternate Employee Expenses $10,000 Extra Territorial Workers Compensation $1,000,000 Hire Car Excess Reimbursement $2,000 Security Evacuation $25,000