REF: Coach Plus/SL/10/17 Edition 1: Oct 2017

Payment by VISA / MASTERCARD

Payment by Cheque

To process this payment we need the 3 digit security number on the reverse of your card.Please provide a daytime contact number, so that we may call you for this purpose.

PLEASE USE BLOCK CAPITALS

Title

Geographical Areas (for definitions see overleaf)

Delete Excesses

EuropeCI/EireUK

Departure Date / /

Card valid from /

Date / /

Return Date / /

Card expiry date /

No. of Days

Total:

Address

Telephone number

Telephone number

Cardholder’s signature

Cardholder’s name

Email

Signed

Postcode

Please debit my card with £

Card Number

Postcode

Agency Stamp

Address (if different from application form)

Initials Surname

To obtain cover, please complete the Application Form opposite and return it, with your payment to:

Coach PlusP J Hayman & Company LimitedStansted HouseRowlands CastleHampshirePO9 6DX

P J Hayman & Company Limited are authorised and regulated by the Financial Conduct Authority (No. 497103). Registered in England No. 2534965.

2017/18www.coachplusinsurance.co.uk

APPLICANT

COVER REQUIRED

PREMIUM SUMMARY

Names of ALL persons to be insured (if more than 5 please attach a ‘group’ list)

1.......................................................................................................Age..............

2.......................................................................................................Age...............

3.......................................................................................................Age...............

4.......................................................................................................Age...............

5 ......................................................................................................Age...............

DECLARATION: I declare that I have read for myself and on behalf of those persons for whom I have arranged cover, the ‘Important - Medical Conditions‘ (overleaf). I confirm there are no circumstances that could be reasonably expected to give rise to a claim.

£

Infants (under 2)

Children (2 - 17)

Adults (18-74)

Adults (75 & over)

FREE

@ £

@ £

@ £

Delete Excesses (£6.54 per person) £

Please make your cheque payable to: P J Hayman & Company Ltd and send with this completed form to the address shown below.

No age limits

No medical screening

Apply by post or call 02392 419 855We are open Monday to Friday, 8am - 6pm, closed Bank Holidays

Application Form

UK & European Coach Holiday Insurance

Coach Plus

Show the number of persons travelling within each age band and the total premium payable.

UK & European Coach Holiday Insurance

Coach Plus

Specially designed for coach holidays in the UK & Europe

Great value cover from just £4.85!

Peace of mind with 24/7 emergency medical assistance

Additional information

Preparing for a coach holiday is exciting but don’t forget to take out adequate travel insurance as soon as you have booked your trip, just in case the unexpected happens!

You could be faced with a large bill, but Coach Plus can help.

What would happen if you fell ill and had to cancel your holiday or if you had an accident abroad and needed urgent medical treatment ?

Coach Plus has been specially designed to provide you with the essential cover you need for a coach holiday, from cancellation and loss of deposit to emergency medical costs and repatriation home.

A 24-hour emergency medical assistance helpline is also included.

Coach Plus offers you protection from as little as £4.85 for a one day trip in the UK.

See opposite to find the premium for your particular trip.

Every year, Coach Plus settles many claims for unforeseen eventualities for coach travellers.

So why not cover yourself with Coach Plus - you can then look forward to and enjoy your holiday with complete peace of mind!

Eligibility

Coach Plus is available to people residing in the UK or the Channel Islands and who are registered with a doctor in the UK or the Channel Islands.

Your cancellation rights

Should the cover not meet your requirements after you have purchased the policy, you can return the documentation within 14 days of receipt.

Provided you have not travelled or made or intend to make a claim, your premium will be refunded in full.

Premium notes1. Excess waiver - for an additional premium of £6.54 per person, the standard claims

excess can be deleted. This will mean that in the event of a claim, the standard excess is reduced to Nil.

2. Winter sports cover - 2x premium per person (maximum age 74 years or under).3. Child discounts - children aged 2-17 years – 50% discount if accompanying a related

insured adult. Children under 2 years, free of charge.4. Group discounts (number of people):

20 to 40 = 10%, 41 to 75 = 15%, 76 to 100 = 20%, 101 to 249 = 22.5%, 250+ = 25%5. IPT (Insurance Premium Tax) - is included in these premiums at the current rate.6. Geographical & rating areas:

United Kingdom/UK: England, Scotland, Wales, Northern Ireland & the Isle of Man.Channel Islands/CI: Jersey, Guernsey, Sark, Alderney & Herm.Eire: Republic of Ireland.Europe: Albania, Algeria, Andorra, Armenia, Austria, Azerbaijan, Azores, Balearics, Belarus, Belgium, Bosnia-Herzegovina, Bulgaria, Canary Islands, Corsica, Croatia, Cyprus, Czech Republic, Denmark, Egypt, Estonia, Faroe Islands, Finland, France, Georgia, Germany, Gibraltar, Greece (and the Greek Islands), Holland (Netherlands), Hungary, Iceland, Italy, Kosovo, Latvia, Liechtenstein, Lithuania, Luxembourg, Macedonia, Madeira, Malta, Moldova, Monaco, Montenegro, Morocco, Norway, Poland, Portugal, Romania, Russia, San Marino, Sardinia, Serbia, Sicily, Slovakia, Slovenia, Spain, Sweden, Switzerland, Tunisia, Turkey, Ukraine, Vatican City.

Period up to (days) UK CI/Eire Europe1 £4.85 £4.85 £5.282 £6.67 £7.74 £9.473 £9.31 £10.51 £11.704 £11.10 £14.05 £17.575 £12.88 £15.84 £19.796 £13.14 £16.74 £20.937 £13.66 £17.87 £22.278 £15.07 £18.74 £23.419 £16.99 £19.62 £24.5410 £17.68 £20.53 £25.6311 £18.42 £21.41 £26.7712 £19.09 £22.32 £27.9013 £19.84 £23.23 £29.0414 £20.51 £24.16 £30.18

Extra days (max 31 in all) £0.92 £1.09 £1.31

Persons aged 18 - 74 years

Persons aged 75 years & overPeriod up to (days) UK CI/Eire Europe

1 7.26 7.26 7.922 £10.02 £11.60 £14.213 £13.98 £15.78 £17.524 £16.67 £21.10 £26.355 £19.31 £23.76 £29.706 £19.70 £25.12 £31.397 £20.48 £26.82 £33.428 £22.61 £28.13 £35.129 £25.49 £29.44 £36.8310 £26.51 £30.80 £38.4611 £27.62 £32.11 £40.1612 £28.64 £33.49 £41.8713 £29.74 £34.86 £43.5714 £30.77 £36.24 £45.28

Extra days (max 31 in all) £1.37 £1.64 £1.96

£ £ £

This is a summary . Full terms and conditions can be found in the policy wording, a copy is available from your Broker / Agent or direct from P J Hayman & Company Limited on 02392 419 855 www.coachplusinsurance.co.uk

only

or our website

Cancellation & Curtailment £5,000 £50 (£15 loss of deposit or trips under £100)

Medical & Incidental Expenses £5,000,000 £50(not your home country)

Hospital Inconvenience Benefit £1,000 (£25 per 24 hours) Nil(not your home country)

Repatriation & Emergency Expenses £10,000 £50

Personal Accident £15,000 Nil

Personal Possessions £2,000 £50

Delayed Personal Possessions £150 Nil

Personal Money £500 £50

Loss of Passport/Travel Documents £250 Nil

Personal Liability £2,000,000 Nil (£100 damage toaccommodation per party)

Travel Disruption £1,000 Nil

Travel Delay (not your home country)

- Delay £150 (£30 per 12 hours) Nil

- Abandonment £5,000 £50

Legal Expenses £25,000 Nil

Before applying for cover, you and each person to be insured must consider the following:

All claims are excluded where at the time of booking your journey, taking out this insurance or paying any further balance or instalments:

1.The insured person:

(i) is aware of any set of circumstances which could reasonably have been expected to give rise to a claim; or

(ii) has suffered from a chronic or recurring medical condition during the previous 12 months UNLESS permission is obtained from the treating doctor of fitness to travel at the time of booking; or

(iii) is travelling against the advice of a doctor or where they would have been if they had sought their advice before beginning the trip; or

(iv) knows that they will need treatment or consultation at any medical facility during the trip; or

(v) is travelling for the purpose of obtaining and/or receiving any elective surgery, procedure or hospital treatment.

2.The person whose condition gives rise to a claim:

(i) is receiving, or on a waiting list for treatment in a hospital or nursing home; or

(ii) is awaiting the results of any tests or investigations; or

(iii) has been given a terminal prognosis.

Cover Limit (up to)per person

Excess per person(unless shown)

Premiums Summary of Cover

Important - Medical Conditions

Valid from 1st October 2017.Travel must take place within 18 months of the start date of your policy.