Green Card Request

Our reference*

Our reference appears on the top left hand corner of any of our letters we send to you.

Please enter the policy number as it appears in the policy documents*

Please enter policyholder name as it appears in the policy documents

Title*

Other title*

Policyholders First name*

Policyholders Surname*

Phone*

Address*

Street Address Address Line 2 Town/City County Postcode Country

Please enter the policyholder address as it appears in the policy documents The combined length of policyholder name, address and postcode, including spaces and punctuation, is limited to 103 characters If the policyholder is a company and the address stated on the policy documents is unknown, use the company’s UK registered office address.

Please enter details of the current period of insurance as it appears in the policy documents:

You can only use this facility to request a Green Card that falls within the current period of insurance. If the policy falls due for renewal part way through the intended period of travel you will need to renew your current policy and request a separate Green Card from the renewal date, or request a Green Card from the new insurer for the date they are providing cover.

Start Date*

End Date*

Please enter dates the Green Card is required for:

The minimum period a Green Card can be issued for is 15 days. If the proposed trip is less than 15 days, please use 15 days, unless the policy expires less than 15 days from the start date of your Green Card. If the policy expires less than 15 days from the date of travel, you will have to request a new Green Card for the remainder of the trip if you have renewed your policy with us, or from the new insurer.

Start Date*

End Date*

Countries that are being travelled to*

Please list each country you are travelling to separately.

Country

Important Information

Green Card Charges

Name