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* Denotes required information.
Insured's Details
  First Name: *
  Last Name: *
  Known As: *
  Country of Nationality: *
  Country of Service: *
  Date of Birth:
Day Month Year Sex  
Family Members (Dependants requiring Insurance)
  1st Child:
  2nd Child:
  3rd Child:
  4th Child:
  5th Child:
Email Address
  Email Address: *
  Please Repeat: *
Contact Address
  Address Line 1:
  Address Line 2:
  Address Line 3:
  State / Zip:
  Tel No:
Program Details
  Start Date: *
  End Date: *
Credit Card Details
Note: Unless your church or mission has a prior arrangement to pay us directly, all the following credit card details are required to process your enrollment.
  Name of Card Holder:
  Credit Card number:  (Visa or MasterCard only)
  Verification Number: **
  Card's Expiry Date: /
**The 3 digits on the back of your card.

By clicking the 'Submit' button below, you are declaring that you have read, understood and agree to the following 5 points:

  1. I declare that I have read, understood and agree to the terms of the Legal Wording. Legal Wording PDF

  2. I declare that all the information supplied in respect of all persons on this Enrollment Form is true and complete.

  3. I understand that no cover is provided for hazardous activities and any professional sporting activity that includes, but is not limited to:

    Bungee jumping; Flying other than as a fare-paying passenger in a licensed passenger aircraft; Motor rallies or competitions; Motorcycle sports (as the rider or as a passenger); Mountaineering, abseiling or rock climbing requiring the use of ropes and/or guides; Parachuting, para-sailing or para-scending; Pot-holing; Racing of any type other than on foot or while swimming; Kite board sailing; The use of any bob sleighs, luge or skeletons; Off-piste skiing, glacier skiing, ski-jumping, ski-flying, ski-bobbing, ski-acrobatics, ski-stunting and heli-skiing; Participating in any form of ice hockey; Scuba diving to a depth of greater than 30 metres. Please refer to legal wording for detailed exclusions.

  4. I understand that I may not complete this enrollment until such time that all material facts * in connection with this enrollment, have been declared in full, without misstatement or misrepresentation and have been accepted by us in writing. I understand that failure to do so will result in cover being void from inception.

  5. I understand that pre-existing conditions are not covered. (A pre-existing condition is any disease, illness or injury, secondary or associated complaint for which you have sought or received advice, treatment, therapy or been submitted to a special diet - whether or not the condition has been diagnosed).
* A material fact is any piece of information that may affect our assessment or acceptance of your enrollment for insurance. If you are unsure as to whether any piece of information is a material fact, it should be declared.

If you agree to all the above, please type 'I Agree'
(Please type exactly as shown, without the quotes) in the confirmation box.

Confirmation Box:



Important: As no signature is required, the submission of this form will be considered your legal agreement to the terms and conditions of the contract


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