European Travel Insurance - SINGLE TRIP POLICY

DO NOT USE THIS FORM UNLESS YOU ARE TRAVELLING ON AN MCi TOUR.
IF YOU ARE MAKING YOUR OWN TRAVEL ARANGEMENTS AND REQUIRE INSURANCE PLEASE CONTACT
GOLD COVER DIRECTLY ON: 01892 559 530 QUOTING 'MCi TOURS'

Complete the form below, print-out, sign and send to: MCi TOURS P.O. Box 750, Altrincham, Cheshire, WA15 8GE
with the appropriate premium. or click 'Send' and forward your premium within 7 days to activate your policy.
Please note that MCi Tours will not pass on your details to third parties
European Motoring Breakdown Assistance
tick Repatriation of rider, passenger and luggage to UK
tick Replacement vehicle - up to £1000
tick Roadside assistance and towing up to costs incurred
tick Emergency repairs (NOT parts) - up to £100 towards labour cost
tick Delivering replacement parts (but not the cost of them) - no limit
tick Cost of repatriating bike if unable to repair up to vehicle
tick Collection of bike left abroad for repair up to £600
tick Additional accommodation - up to £225 per person
tick Provision of alternative rider - no limit
tick Bail bond, legal advice and legal expenses up to £10,000
Personal Travel Insurance Summary of Cover
per person
tick Departure Delay up to £100
tick Cancellation and curtailment up to £3,000
tick Medical Expenses & Repatriation up to £5 million
tick Hospital Confinement up to £500
tick Loss of Passport up to £250
tick Missed Departure up to £1,000
tick Personal Accident up to £25,000
tick Personal money up to £500 (cash £250)
tick Baggage and Personal Possessions up to £1,500
tick Legal liability up to £2million
tick Legal expenses up to £25,000
Length of Tour Combined Breakdown and Travel Policy SINGLE Person
Bike < 10yrs old		 Combined Breakdown and Travel Policy TWO Adults
Bike < 10yrs old		 Personal Travel
Policy only
Cost Per Person
1) Up to 3 days £39.95 £55.90 £15.95
2) Up to 5 days £49.95 £71.90 £21.95
3) Up to 10 days £69.95 £99.90 £29.95
4) Up to 17 days £79.95 £114.90 £34.95
5) Up to 24 days £89.95 £129.90 £39.95
6) Up to 31 days £99.95 £149.90 £49.95
Extra week (max 60 days) £29.95 £46.90 £16.95
Telephone: 0161 941 7149 Fax: 0161 941 2121
 
I am travelling on MCi Tour number:

 to:
Start Date (Outward Ferry Ticket)
Finish Date (Return Ferry Ticket)
Total No. of Days Covered:
   
Please provide
cover for one of the following:		 me and my
motorcycle
£ 		me, my motorcycle and
my pillion
£ 		Personal Travel
Cover only
£
{PaymentNote}

YOUR DETAILS

Rider Name Date of Birth
Pillion Name Date of Birth
Address Post Code
Email
Daytime Phone Mobile

YOUR MOTORCYCLE

Registration No Year
Make Model

Please note Medical Screening on pre-existing conditions is mandatory.
If you have a medical condition YOU MUST call the Helpline on 0870 774 4408 and quote Policy Reference Gold Cover UK UL.

Motorcycle Rider (& Pillion if applicable) Declaration: My motorcycle is not over 10 years old. I am/We are: 1) not travelling against the advice of a medical practitioner 2) not aware of any reason why the trip should be cancelled or curtailed 3) not on a course of medication that would make me/us an abnormal risk 4) not over 80 years of age.

Rider Signature
 
Date
           /            /
Pillion Signature
 
Date
           /            /
OR