Travel Insurance Medical History Form
Please give a complete answer for each question. All aspects relating to the risk must be disclosed. Any non-disclosure may render the Travel Insurance contract null and void or may adversely affect the rights under the cover.
Travelling to
*
Travel Dates From
Until
When can you be contacted by our Team
At what time?
Last Name
*
First Name
*
Date of Birth
Document upload - ID or any other
Add More Files
Max size: 5MB
City
Country
Occupation
Marital Status
Email
*
Mobile Number
*
Purpose of Travel
Have you undergone medical treatment over the past 12 months?
Yes
No
Have you undergone surgical operation over the past 12 months?
Yes
No
If Yes, please disclose full details
Are you currently suffering from any illness or disease, malformation, or physical or mental handicap?
Yes
No
If yes please disclose full details
Are you currently undergoing medical treatment, under medical supervision or expect to undergo medical treatment within the next 12 months?
Yes
No
If yes please disclose full details
High blood pressure, cholesterol issues, heart disease (chest pain, heart attack), or stroke.
Yes
No
Diabetes Mellitus, Renal or Liver disorder
Yes
No
Cancer, Tumor or Cust of any type
Epilepsy, Mental or Nerveous Disorders
Yes
No
Disorder of Respiratory System, Lung or Chest
Yes
No
Any Other Disease
Yes
No
If Yes , please disclose full details
*
Have your parents ever suffered from diabetes mellitus, heart disease, high blood pressure, stroke, kidney disease, liver disease, Hepatitis B or C, cancer or any other genetic disease
Yes
No
If yes, please disclose full details
I hereby declare that all answers are true and correct and that I have not withheld any information which would have influenced the Insurer’s decision to accept or decline the application. I am fully aware of the terms, conditions and exclusions applicable under the Travel Insurance contract which has been subscribed with Quantum Insurance Ltd.
Medical Underwriting
Submit
