Travel Insurance Application - Mavel

Prize reference code*

This number was provided to you when you were notified that you won the prize and starts with a 3-digit number followed by your surname. If you cannot locate this reference number please contact Mavel prior to submitting this form.

Surname*

Exactly as it appears on your drivers licence (domestic travel) or passport (international travel)

Title*

First name*

Exactly as it appears on your drivers licence (domestic travel) or passport (international travel).

Are all travellers currently living in Australia, and:- are they Australian citizens with a valid Australian Medicare card, or - do they hold a visa allowing them to live, work or study in Australia?

Yes
No

Do any travellers require:*

Additional luggage cover (e.g you're taking high-value items)?
Motorcycle/Moped Riding cover?
None of the above

Existing Medical Conditions and Pregnancy

"Do any travellers have an Existing Medical Condition or Pregnancy?" We call an Existing Medical Condition (EMC) any disease, illness, medical condition, dental condition or physical defect that you have or have had - even if you're cured, or if it's under control or in remission. Some existing medical conditions are automatically included. For others, you need to complete an online medical assessment by telling us all your conditions. If your conditions are approved by the Insurer, you can then decide to buy the cover you need. An extra premium applies. That's why it's important you carefully answer these questions to understand if any traveller has an Existing Medical Condition that requires an online assessment.

Do you have a pre-exisitng medical condition? If so, please provide details below?

In the last 12 months, has any traveller been hospitalised or treated in the emergency department, seen a specialist, or had day surgery?

Yes
No

Has any traveller ever had a medical condition or required surgery involving any of the following?

• Kidneys, Liver • Cancer (even if in remission) • Joint, back or spine • Brain e.g. Dementia, Epilepsy, head injury, Tumours • Any heart-related condition e.g. Angina, bypass surgery, heart attack, irregular heart rhythms, stents • Strokes e.g. clots, Deep Vein Thrombosis, mini strokes, Pulmonary Embolism • Respiratory system e.g. Chronic Bronchitis, COPD, Emphysema

Yes
No

Is any traveller experiencing any signs or symptoms where a medical diagnosis has not been sought?

e.g. chest pain, shortness of breath, a persistent cough or unexplained bleeding.

Yes
No

If any travellers are pregnant:

• Have there been complications with this or a previous pregnancy? • Is it a multiple pregnancy e.g.twins or triplets ? • Was the conception medically assisted? e.g. using assisted fertility treatment including hormone therapies or IVF (Pregnancy cover is limited to unexpected complications up to the 24th week. Childbirth or care of a newborn is not covered)

Yes
No

If pregnant, please confirm due date (in weeks and day):

I understand that failing to properly disclose medical history and changes to my health can result in my travel insurance policy being cancelled or my claim being denied if I require treatment while travelling, leaving me obligated to cover any associated costs?

Yes, I understand