"*" indicates required fields Step 1 of 4 25% Your DetailsName* First Last Address* Street Address Suburb State Postal Code Contact Number*Email* Period of InsuranceCoverage Start Date* DD slash MM slash YYYY Policyholder NameABNTrading NameBusiness Occupation Note: Travel activity estimates (1 Insured Person travelling = 1 return trip) e.g. A director and 4 employees (or 4 accompanying family members) travelling together on the same trip = 5 trips DomesticInterstateTotal number of tripsAverage duration (days)Maximum duration (days)IntrastateTotal number of tripsAverage duration (days)Maximum duration (days)Domestic (overseas)Total number of tripsAverage duration (days)Maximum duration (days)OverseasAfricaTotal number of tripsAverage duration (days)Maximum duration (days)AsiaTotal number of tripsAverage duration (days)Maximum duration (days)Europe & UKTotal number of tripsAverage duration (days)Maximum duration (days)Middle EastTotal number of tripsAverage duration (days)Maximum duration (days)North America & CanadaTotal number of tripsAverage duration (days)Maximum duration (days)New Zeland & Pacific IslandsTotal number of tripsAverage duration (days)Maximum duration (days)South & Central AmericaTotal number of tripsAverage duration (days)Maximum duration (days) Maximum number of Insured Persons travelling together on a Business Trip:Will any Insured Persons be travelling to remote or high risk locations that the Australian Government recommends travellers to not travel?*SelectYesNoPlease provide detailsWill any Insured Persons be engaging in activities including sports?*SelectYesNoPlease provide detailsHave you made any travel insurance claims in the last 5 years?*SelectYesNoPlease provide detailsDate of incidentDescription of the lossAmount paid by the insurer Add RemoveConsent* I agreeNon Disclosure: If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning. In addition to the above, following documents can be viewed on our website: PRIVACY POLICY: https://www.imcinsurance.com.au/privacy/ FINANCIAL SERVICES GUIDE (FSG): https://www.imcinsurance.com.au/financial-services-guide/ CONTACT US: IMC Insurance Brokers Pty Ltd | ABN 79 676 680 946 | AFSL 229344 Level 1 251-253 Malvern Road, South Yarra, VIC 3141 | 1300 251 253 | insure@imcinsurance.com.au Δ
