ACROSS THE DIVIDE OPEN CHALLENGES
INSURANCE FORM

Clients travelling must take out Across the Divide travel insurance. It is a competitively priced policy that provides the required amount of cover. This insurance covers among other things, medical arrangements including evacuation and repatriation.

Please note that if you are extending your stay in-country you must inform us of your return date to ensure that you have adequate cover.

Participants are obliged to disclose if they are suffering from any pre-existing medical condition. You do not have to provide details on this form but you need to check with the insurer’s medical helpline in confidence on 0844 892 0954. An immediate assessment will be given.

FAILURE TO DISCLOSE A PRE-EXISITING MEDICAL CONDITION COULD INVALIDATE YOUR INSURANCE.

Fields with a * are compulsory

 

I suffer from a pre-existing medical condition and will/have declared it to the Medical Screening Facility

I do not currently suffer any pre-existing medical condition

The event I am entering is:

Personal Details

*Title:

*First Name:

*Surname:

*Sex:

*Date of Birth:

*Age

*Home Address:

*Postcode:

*Daytime phone number:

Mobile phone number:

Evening phone number:

*Email address:

 

The premium payable for 2008 is:

  • Morocco - £38.00
  • China, India Bike Ride, Jordan & Namibia - £45.00
  • Peru, Ladakh, & Kilimanjaro - £51.00
  • Everest Base Camp - £62.00
  • Dog Sledding - £76.00

*Please select the premium for your trip:

The above prices are only applicable before the 31 December 2008. Insurance premiums issued after this date may be subject to increase.

For participants over 65 years of age at the time of departure, the premium is doubled. Also an additional £9.00 (or £18.00 if over 65) is charged per week, or part thereof, for any participant extending their stay in country.

I have read and agree to abide by the Insurance Summary

 

 

 

 

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