Upgrade for additional cover for high value specified luggage items newly purchased (you may be requested to supply a receipt showing value and purchase date).
The policy limit for any one item, set or pair of items is $2,500 unless the item, set or pair of items is specified and additional premium is paid.
(Additional premium will be charged at a rate of 2% of the full value of the item.) Lesser valued items of luggage are covered under the general luggage allowance.
Please refer to the Destination Exclusions for a list of countries which are not covered.

APPLICANT DETAILS

Enter Title, Name and Date of Birth of insured person:-

Main contact address - Place each part of the address on a new line.


Main contact telephone

Main contact fax

Email address for Upgrade Certificate of Insurance Must be a working email address. Hotmail users please check your junk box.

Main Uni-Care policy number Enter "Pending" if main policy is not yet issued.

Personal notes relating to your application

DECLARATION (Please read carefully)

1. You confirm details have been correctly declared in this application form.

2. You authorise any claim to be paid to any named institution which has submitted claim details and requested payment to be made to them on your behalf.

3. You accept that failure to supply correct application details may affect the validity of the policy.

4. You have certain rights of access to and correction of this information.

5. You understand and agree that the act of transmitting this application to Uni-Care, by activating the 'Submit Application' button on the web application form, will have the legal force of a signature, will implement an application for insurance and will authorise Uni-Care to deduct the premium from the credit card detailed above (or invoice an educational institution if appropriate and agreed by us).

6. I understand that the Policy Wording and Benefits Payable displayed in this website today are those applicable to the policy I am purchasing today, and may have changed since I held a previous policy.

7. You have read and understood and accepted the above statements and accept responsibility for all the information provided in this application.

Declaration Box - The Declaration Box must be clicked in order for your application to be submitted.
APPLICANT STATEMENT: I have clicked in the Declaration Box as proof of the fact that I have read, agree and accept the above Declaration which is a compulsory element of the Uni-Care on-line application form.

PAYMENT DETAILS
Applications cannot be processed until payment has been received.

Please select one of the following payment options.
Direct Credit payments must be done immediately you receive our bank account details by return email.

IMPORTANT
1. Check the MFAT Foreign Country Travel Safety Reports and your itinerary before you submit this application.
2. If you wish to keep a copy of your online application form or retain a record of the calculated premium, print this form out now.

Click on this button only once. There may be several seconds delay before an acknowledgement appears. If you click twice we receive two application transmissions. We remind you that a correct working email address is essential for our confirmation.