First Traveller's Name* Tel No Mobile E-mail Date of Birth (MM.DD.YYYY) Address Post Code Passport No Expiry Date (MM.DD.YYYY) Next of kin Tel No: Address: Post Code: Second Traveller's Name Tel No Mobile E-mail Date of Birth (MM.DD.YYYY) Address Post Code Passport No Expiry Date (MM.DD.YYYY) Next of Kin Tel No: Address Post Code: Doctor's Name Tel No: Address (1) Can we contact him/her?  yes  no (2) Do you require our Personal Assistance Package?  yes  no (3) Do you use a wheelchair?  yes  no (4) Can you propel yourself?  yes  no Important If you have ticked the "NO" to Question 2 and "YES" to Questions 3 and 4 please note that you will have to propel yourself at all times including during excursions. Type of wheelchair   Manual  Electric  Scooter Weight If you wish to decline our own travel insurance If you do not tick this box, insurance should automatically be added to your deposit, otherwise you will not be covered.   Holiday Destination Tour No Deposit / Full Payment Enclosed Have you travelled with us previously?  yes year  no How did you hear about us?  Yours  Choice  Lady  Woman's Weekly Other INSURANCE DETAILS Travelling Insurance is a very important part of any holiday arrangements.The policy used by Chalfont Line Holidays is operated by City Bond. HEALTH Whilst the insurance is not subject to a health warranty, Underwriters shall not be liable for claims WHERE AT THE TIME OF PURCHASING THIS INSURANCE: A. The person whose condition may give rise to a claim: Is suffering from anxiety or depression or from any previously diagnosed psychiatric disorder, or Is receiving, or on a waiting list for in-patient treatment in a hospital or nursing home, or Has received medical treatment as a hospital in-patient during the last six months prior to booking the trip unless he/she has obtained satisfactory medical advise on the advisability of taking the trip, or Is expected to give birth before, or within eight weeks of the date of arrival home, or Is travelling against the advice of a Medical Practitioner or for the purpose of obtaining medical treatment abroad, or Has been given a terminal prognosis. B. The Insured Person is aware of any medical condition of a relative, close business colleague or any person on whom the travel plans depend, which could reasonably be expected to give rise to a claim. C. The Insured Person is aware of any circumstances which could reasonably be expected to give rise to a claim. In order to obtain the travel insurance please call the Travel & Medical Helpline on 01689 892 258 quote the “Arch Coach Scheme”, answer the medical questionnaire (screening) over the telephone, you may be issued with a reference number; then please call our reservation department on 01895 459 540 quoting the reference number, we will then issue your travel insurance policy.