Departure Date (Days of departure and return in period of cover)

Will you be participating in any hazardous activities, including sports such as diving, skiing, mountaineering, motorcycling?YesNo

Will you be visiting Canada/USA?
YesNo

Declaration

1. I declare that to the best of my knowledge and belief, All persons proposed for this insurance at the time of effecting this insurance
- are free from any illness or infirmity and are not undergoing any treatment which could result in medical expenses being incurred.
- have not made any claim under this type of insurance or similar during the past 3 years.
2. I agree that this proposal is for insurance in the normal terms and conditions of the
Insurers policy and shall form part of the insurance contract.