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GROUP ACCIDENT AND ILLNESS PROPOSAL

FOR COVER UNDER THE OVERSEAS TRAVEL, HEALTH AND ACCIDENT INSURANCE POLICIES ARRANGED THROUGH CHRISTIANS ABROAD. (Note: Christians Abroad is the agent, not the provider)

ALL SECTIONS MUST BE COMPLETED IN CAPITAL LETTERS

NAME IN FULL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ADDRESS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
POST CODE/ZIP CODE
E-MAIL, TELEPHONE or best contact method    
ORGANISATION RECRUITING YOU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
COUNTRY IN WHICH YOU WILL WORK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   
OCCUPATION OVERSEAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
ESTIMATED DATE OF DEPARTURE. . . . . . . . . . . . . . . .and RETURN . . . . . . . . . . .  
DATE OF BIRTH . . . . . . . . . HEIGHT . . .  WEIGHT . . .  
TYPE OF COVER REQUIRED   Manual * Gap Year Essential Comprehensive  
*  Note: Manual cover is not available for people over 65.
Those in full-time education up to age 23 may qualify for special rates.  

ARE YOU AT PRESENT IN SOUND HEALTH AND FREE FROM PHYSICAL DEFECT OR INFIRMITY? YES NO If you are not please give details on a signed accompanying statement.

HAVE YOU IN THE PAST 12 MONTHS YEARS HAD ANY ILLNESS OTHER THAN COLDS OR INFLUENZA OR ANY INJURY WHICH HAS INCAPACITATED YOU FOR MORE THAN A WEEK? If so, please give the following particulars of each and every occasion in answer to the following questions in a signed accompanying statement:
  a) What was the cause?  
  b) When was it?  
  c) How long were you incapacitated for?
PLEASE SIGN THE FOLLOWING DECLARATION

I DO HEREBY DECLARE that the above statements and those accompanying which have been signed by me are true and correct and that this proposal shall form the basis of the Contract between myself and the insurers as set forth in the policy in the name of CHRISTIANS ABROAD. The fee includes a small donation to support Christians Abroad and to help cover administration costs.

SIGNED ....................................................... DATE .......................................

Post: Christians Abroad, 237 Bon Marché Centre, 241-251 Ferndale Road, London, SW9 8BJ, England

Charity 265749 | Christians Abroad | London | England | Copyright 2008 ©