Manual policies online form 1Details2Confirmation Main ApplicantName(Required) First Middle Last Email(Required) Phone/Mobile(Required) Date of Birth(Required) DD slash MM slash YYYY Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please note USA, Canada, Australia, Iran, North Korea, Syria, Cuba, Crimea, Belarus, Russia, South Sudan, and Venezuela as the home country are excludedTravel Information battleface Policy cannot be purchased more than 365 days in advanceAre you already travelling?(Required)if already travelling, cover will start 24-hours after purchase Yes No Start Date(Required) DD slash MM slash YYYY End Date(Required) DD slash MM slash YYYY Destination(Required) Please list all countries you will be travelling to. Example: Spain, Portugal, AustraliaAdditional TravellersFull NameDate of Birth Add RemoveConsent(Required)To purchase battleface Travel Medical Insurance, EACH applicant MUST be able to confirm the following statements: I have (or will have) received all immunisations recommended by a qualified doctor in my Home Country prior to entering the destination country.I will be over one month old on the date I require cover to commence and under 80 years on the date I require cover to cease.I will not be an active member of any military or para military force at any time during the Policy Period. I acknowledge these Terms and ConditionsFor information about how we collect and process your data, as well as your rights, please see our privacy policy. Confirmationstatement(Required)I, the Main Applicant have been authorised by each of the persons named in this application to apply for this insurance on their behalf, and confirm that a copy of the Policy Summary Insurance Product Information Document and Policy Document has been made available to each Applicant for review prior to purchasing this insurance. I and each of the Applicants: have confirmed that they can answer Yes to the Eligibility Statements detailed in step 1 of this Application. reside at the same address, being the address provided in this Application. request and expressly agree that this insurance policy be provided to me in English, that this insurance shall be governed exclusively by the law and practice of England and Wales unless otherwise required by applicable law, and that all communication of and in connection with this Policy shall be in the English language. understand the insurance applied for is not a general health insurance policy, but is intended to cover unforseen injury or illness occurring outside my/our Home Country, during the journey for which I/we are buying cover, and contains a Pre-existing Condition exclusion, a Pre-certification process and other restrictions and limits. understand that other taxes or costs may exist that are not paid through the Plan Administrator or imposed by it. understand that my/our insurance terminates upon returning to my/our Home Country. hereby apply to Lloyd’s through battleface Insurance Services Limited for the insurance described in the battleface Policy Document. agree to receiving my policy documents via email Please tick this box to confirm the statements above and to continue purchasing this insurance.(Required)pre-contractual info(Required)The insurance you have applied for is underwritten by certain underwriters at Lloyd’s of London, One Lime Street, London EC3M 7AH. The Coverholder under which the Plan has been placed with Underwriters under Unique Market Reference B0621F33104822 is battleface Insurance Services Limited, Suite 24, 80 Churchill Square, Kings Hill, West Malling, Kent, ME19 4YU, UK. The Coverholder acts as Underwriters’ agent in binding risks, issuing documentation and the collection and processing of premiums and return premiums. Full details of the complaints procedure and the Policy cancellation provisions are detailed in the Policy Summary and Policy Document. Information provided to Underwriters will be processed by them and their agents in compliance with the provisions of the General Data Protection Regulations 2018 of England and Wales, for the purpose of administering this insurance and handling claims, if any. The information may also be sent for processing to other entities, including those located outside the European Economic Area and others where there is a legal obligation to provide it. As a consumer, you have a duty to take reasonable care to answer questions fully and accurately. This duty exists before coverage is placed and throughout the entire duration of the insurance. If you do not do so, your insurer may be able to void the Policy from inception. This policy meets the needs of those who require personal accident and medical expenses cover whilst travelling or working abroad. It also meets the needs of those travelling to potentially dangerous territories and conflict zones and therefore may require enhanced benefits and limits such as crisis response, evacuation, war and terrorism, kidnap and political threat coverage. You have chosen the benefit limits which meet your individual requirements. We have not made any personal recommendation as to the suitability of this product. We arrange a policy with the insurer on your behalf. You do not pay us a fee for doing this. We receive commission from the insurer which is a percentage of the total annual premium. I request and expressly agree that this insurance policy and all pre-contractual information be provided to me in English and confirm that I understand and accept the contract and agree to be bound by its terms and conditions.(Required)language(Required) I understand and agree that this insurance is subject to English law unless otherwise required by applicable law.(Required)data info(Required)battleface Insurance Services Limited, Lloyd’s of London and other related insurance market participants may need to collect certain Special Categories of Personal Data about you in connection with your insurance cover, such as any pre-existing medical or other health conditions. You are not under any obligation to consent for us to process your health information and may withdraw your consent at any time by emailing [email protected]. However, if you withdraw your consent this may result in us applying a restriction on your policy or in some instances, withdrawing your cover altogether. I consent to the use of certain special categories of personal data such as information on my racial or ethnic origin, genetic or biometric data, health, set life, or sexual orientation in connection with my insurance cover.(Required)Please click here to read through the insurance product information document.product docs(Required) I acknowledge that I have read through insurance product information document.(Required)store my name I agree to store my name and email address to receive updates, newsletters and commercial offers from battleface.register I would like to register for a battleface account.
