Welcome to Max Insurances
Phone 0508 629 5626
D1, 27-29 William Pickering Drive, Rosedale, 0632
Tel: 09 913 3011 Fax: 09 913 3012
Your Name
Date of Birth
Your Address
Contact Number
Your Email
Where are you travelling to
Who will be travelling & their ages
Date of Departure
Date of Arrival
Are you a NZ resident YesNo
Do you understand that travel insurance does not cover any pre-existing medical conditions YesNo
Comments & any other relevant information that may affect the insurance cover
Declaration: I/WE HEREBY DECLARE AND WARRANT that the answers given above are in every respect true and correct, and that I/We have not withheld any information within My/Our knowledge likely to affect the decision of the Company as to My/Our eligibility for insurance. This request and declaration shall be the basis of the quote request. YesNo
