Below is a summary of the information you provided. You may wish to print this page as a reference.
Pax | Prefix | First Name | Middle Name | Surname | Preferred Name | Date of Birth |
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1 | ||||||
2 | ||||||
3 | ||||||
4 |
Email:
Address:
Home Phone:
Work Phone:
Mobile Phone:
Pax | Program | Membership No. | Program | Membership No. |
---|---|---|---|---|
1 | ||||
2 | ||||
3 | ||||
4 |
Pax | Passport Number | Date of Issue | Date of Expiry | Nationality |
---|---|---|---|---|
1 | ||||
2 | ||||
3 | ||||
4 |
Please note that Exclusively Cruising can only offer general advice regarding travel insurance. We recommend that you read the PDS brochures for each quotation that will be emailed to you with your quotation. If you require further information after reviewing the PDS, we would suggest that you contact the customer service number provided with the quotation for each company Exclusively Cruising can only base your travel insurance quote on the information provided to us.
Quote for travel insurance:
Insurance Company Name:
Policy Number:
Insurance Emergency Contact Number:
Pax | Emergency Contact Name |
Relationship to Passenger | Address | Daytime Phone Number |
|
---|---|---|---|---|---|
1 | |||||
2 | |||||
3 | |||||
4 |
NOTE: Due to the Privacy Act (1988), in an emergency situation or if you become injured and/or sick we may be required to pass on your personal details and emergency contact details to authorities such as DFAT or emergency services. If you can please confirm your permission:
Yes, please pass my details on in an emergency:
Date:
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