Travel Insurance – Assessment of Demands and Needs

Insurance Brokers, Companies and Intermediaries

Other Insurance Brokers, Insurance Companies or Insurance Intermediaries that you have approached for quotations to date

Are you an existing MIB Customer?*

Yes
No

Please specify your Customer Number

Which Office would you prefer to use?*

Head Office (Qormi)
Ta'Xbiex branch
Gozo branch

Policy Holder Details

Name and Surname*

Date of Birth*

ID Number*

Email*

Enter Email Confirm Email

Address*

Contact Number*

Business/Occupation*

Travel Details

Commencement Date of Travel from Malta*

Return Date to Malta from Travel*

Destination*

Reason for travelling*

Business - excluding manual work
Pleasure

Type of cover required*

Low Cover
Intermediate Cover
Highest Cover

Sports Activities*

Will you be engaging in any Sporting Activities? If Yes, give details

Yes
No

Sporting Activity Details

Additional Travellers

Name and Surname	ID Card	Date of Birth	Actions

There are no Travellers.

Health Details

Give details of any Health issues that any of the Insured Persons listed has experience in the past 12 months (insurance cover may be restricted or even declines by insurers depending on the condition/s reported and declared by you)

Would you like the policy to be extended for Covid?*

Not all insurers may provide this extension, terms and conditions apply.

Yes
No

Would you like your policy excess to be waived in case of a claim at an additional premium?*

Not all insurers may provide this extension, terms and conditions apply.

Yes
No

Would you like to include the Cancellation of Service cover for cancellations due to adverse weather conditions?*

Not all insurers may provide this extension, terms and conditions apply.

Yes
No

Additional Details

Claims History*

Have you or any other traveler hereby mentioned, had any claim in connection with travelling in the past 5 years or are aware of any circumstance at the time of applying for the travel insurance policy that may lead to cancellation or curtailment of the trip.

Yes
No

Please specify

Additional Comments

Attach any relevant documents.

Drop files here or

Max. file size: 5 MB.

Terms Accept*

I have read and accept MIB's Client Terms of Business & Privacy Policy.*

I understand that by completing this form the data will be processed by MIB in line with GDPR and hereby consent that this data (including if needed sensitive data as defined in article 9 of GDPR) are used for the purposes of providing your insurance services.

I also understand that it is my responsibility to secure and hold the necessary consent from any employees, beneficiaries or other third parties direct or indirectly involved in the insurance proposal/arrangements and whose data will be processed by MIB and the providers of insurance and ancillary services.

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Travel Insurance – Assessment of Demands and Needs

Policy Holder Details

Travel Details

Additional Details

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