Renewal Serious Accident & Emergency Travel Benefit Membership Application

ANNUAL MEMBERSHIP RENEWAL

Enter your current Membership Number

Title

Full Name*

Address*

Please include the postcode

E-mail*

Home Phone / Mobile*

Work Phone (if applicabale)

Date of Birth (dd/mm/yyyy)*

You can include up to three additional people living in South Africa, Australia or New Zealand for Serious Accident Emergency Travel Benefit.

This means that in the event of a Serious Accidental Injury or Accidental Death to either yourself or your included members we will fly either you to them or vice versa on the first available flight. Subject to the conditions of this benefit. The cost is £10.00 per additional person per year.

NOMINATED OVERSEAS PARTNER RENEWAL

Title

Full Name

Address

Please include the postcode

Home Phone / Mobile

Work Phone (if applicable)

Email Address

Date of Birth (dd/mm/yyyy)

Relationship to First Member

SECOND NOMINATED OVERSEAS PARTNER RENEWAL

Title

Full Name

Address

Please include the postcode

Home Phone / Mobile

Work Phone (if applicable)

Email Address

Date of Birth (dd/mm/yyyy)

Relationship to First Member

THIRD NOMINATED OVERSEAS PARTNER RENEWAL

Title

Full Name

Address

Please include the postcode

Home Phone / Mobile

Work Phone (if applicable)

Email Address

Date of Birth (dd/mm/yyyy)

Relationship to First Member