Schemes Available
	Long Stay
	Backpackers
	Study Abroad
	Gap Year
	Medical Insurance
	Hazardous Activities



	Short Stays
	Annual Multi-Trips

COE Connections ©
1998 - 2005

Tel: 01702 587 003
Fax: 01702 316 541

Policy Wording | Policy Features | Site Map

Long Stay Travel Insurance Quote

Please complete this form to obtain a Long Stay quotation (3 months or over) sent in the post.

For an online quote and the option to buy online using SECPay's secure servers, click here.

For a Short Stay quotation (i.e. for trips of less than 3 months) please click here.

Title:

First Name:

Surname:

E-mail:

Address Line 1:

Address Line 2:

Town/City:

County:

Postcode:

Country:

Telephone:

Daytime

Evening

Date of Departure:
Duration of Stay:

Enter the number of those travelling in the following age groups:

0-2 years		3-17 years
18-35 years		36-45 years

Will you be a student studying overseas? Yes No
(If 'Yes', proof of study overseas must be provided)

If so are you under 26? Yes No

Will you be travelling abroad as part of a GAP year programme? Yes No

If so are you under 21? Yes No

Area you want cover for:

Do you intend staying in USA and Canada for more than 30 days? Yes No

Please choose the level of cover required:
(Comprehensive cover must be chosen for trips of less than 7 months)

	Comprehensive		Medical Only
	Baggage Excluded		Hazardous Activities included

Do you have any existing or pre-existing medical conditions?

Yes No

Any other relevant information:

COE Connections International
138 Aylesbeare, Shoeburyness, Essex. SS3 8AG
Tel: 01702 587003 Fax: 01702 316541

All Online Payments Processed on Secure Servers
We accept the following methods of payment: