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PAX Travel Proposal Form

For more information about our travel insurance policy, including eligibility and specific benefits please click here 

Please note the following information:
  • If you do not provide all the information requested, we may be unable to provide a quotation.
  • The Insurers reserve the right to change the premium and/or terms and conditions of cover in certain circumstances. 
  • You should keep a record of all information you have given to us (a copy of a completed form will be emailed to you upon completion)
  • If you have any queries with the below application please contact the PAX team on 0800 212 4800. 

Important information before you apply:
Please note we are unable to offer cover for any trips in, to or through; Afghanistan, Cuba, Iran, Iraq, Lebanon, Liberia, Syria, Sudan, North Korea and the Crimea region. 
Claims will not be covered if any insured person has suffered from, or received any form of medical advice, treatment, or medications for any of the following conditions at the time of booking travel, or purchasing a PAX travel insurance policy, whichever is later:
  • Any heart or circulatory condition, any respiratory condition or cancerous condition
  • A medical condition for which you/they are taking prescribed medication
  • Have been referred to or seen a medical specialist, or needed inpatient treatment within the last 12 months
  • Are receiving or waiting for medical investigation, or treatment for any undiagnosed condition or set of symptoms
  • Have been given a terminal prognosis 

 
Policyholders details
Correspondence address:
This question requires a valid number format.
This question requires a valid email address.
Your Occupation
Travel Details
15. Select type of cover required *This question is required.
Important information: Worldwide Annual Trip Cover provides cover for as many trips as you want, as long as a single trip is not over 60 days in duration.
Important information: Single Trip Cover is suitable if you are making a one-off trip in the UK or abroad, for anything from 1 to 180 days in duration.
Do you require Winter Sports cover?
Cover is provided for up to 17 days for each of these activities in total *This question is required.
Add additional Adventure Cover for activities not listed as standard *This question is required.
View activities covered under Adventure Cover categories A, B or C 
Select the Adventure Cover Category you require *This question is required.
16. Do you require baggage cover *This question is required.
Where are you travelling to? *This question is required.
17. Who do you want to insure *This question is required.
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