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Lead Member Details

Your Title and Name: *

First Name: *

Last Name: *

HASSRA Membership Number: *

Date of Birth:

Your Home Address: *

Your Phone Number (including area code): *

Please Note: Your Confirmation Letter and Insurance Documents will be sent electronically to the Email address you provide.

Email Address: *

Confirm Email Address: *

Would you like to add a family member to your plan? *

Yes

Please note: Couple or Family Cover, the person purchasing the cover must be aged between 40 and 75 years on the date of purchase but any spouse/partner to be insured can be aged under 40. Yours or your spouse/partner’s children can also be covered under this insurance if you choose Family Cover, but children cannot remain covered under this insurance after the renewal date following their 21st birthday. Any child who is aged 17 or under must always be travelling with one of the insured adults on the Insurance Schedule in order for cover to be provided for such child.

Family Member's First Name:

Date of Birth:

Family Member's Last Name:

Gender:

Relationship to Lead Member:

Would you like to add another family member?

Yes

Family Member's First Name:

Date of Birth:

Family Member's Last Name:

Gender:

Relationship to Lead Member:

Would you like to add another family member?

Yes

Family Member's First Name:

Date of Birth:

Family Member's Last Name:

Gender:

Relationship to Lead Member:

Would you like to add another family member?

Yes

Family Member's First Name:

Date of Birth:

Family Member's Last Name:

Gender:

Relationship to Lead Member:

Cover Details

Level of Cover to be Provided: *

Type of Cover to be Provided:

Current Scheme Year or Next Scheme Year:

*Please note: Applications for Insurance cover to begin at next scheme renewal can only be made within 30 days prior to 1st October. As stated on the dedicated HASSRA Travel Insurance website Members can join at any time. Your cover will start once we have processed your application. If you are joining the scheme part way through the year, we will let you know what the proportionate cost will be.

Data Protection Regulation - How your data is managed

To set up and manage your Insurance, we (HASSRA Travel Cover) will hold and use information about you and any of your family members. This information may have been supplied by you, family members or healthcare professionals and providers.
We collect your information through our distributor, Civil Service Insurance Society, and your premium is processed by them on our behalf. Once collected your information will be shared with your insurer, Lloyd’s Syndicate 4444 which is managed by Canopius Managing Agents Limited. Your insurer has appointed Roger Rich & Company Part of the Claims Consortium Group to administer any claims you may have. Should you have a medical emergency your information will be shared with our medical assistance provider. Your information may also be accessible by IT and other contractors for them to meet our operational needs. Your data will be used to provide you with quotes or to administer your insurance, whilst we and those administrating your insurance may analyse your insurance data with that of others to aid product design and performance. None of the controllers or processors of your information will share your information with any other party without your consent. As well as communicating with your healthcare providers we provide non sensitive information to your intermediary (if you use one). When necessary we transfer information to countries outside of the European Economic Area (EEA) though when doing so take steps to ensure companies working for us give an appropriate level of protection.
We call the lead member the “Covered Party” under the Annual Travel Insurance Scheme, and the lead member is the legal owner of the insurance. Because of this, whilst additional persons may also be insured to travel, we send most of our written communications about the insurance and about claims to the lead member.
By signing this form the lead member confirms that:
•
any family members have agreed that the lead member can act for them to incept this travel Insurance
•
the lead member consents on behalf of those family members and themselves to HASSRA Travel Cover using personal information in the ways described above.
We may pass information directly to third parties or by using shared databases. These third parties will include other insurers and law enforcement agencies. This is to prevent or investigate crime, including fraudulent or other improper claims.
If any person would like details of the information that we hold about them they should write to the Data Protection Manager, HASSRA Travel Cover, 1st Floor, Gail House, Lower Stone Street, Maidstone, Kent ME15 6NB.
I agree by signing the Declaration that to administer my insurance my information, as detailed above, may be shared with others. Also, should I wish to restrict or cease the processing of my information cover will no insurance longer be available.
HASSRA may market this product to all its members through its various publications and electronic media.

Declaration

I declare that to the best of my knowledge, the information contained on this application is true and correct; I have read the HASSRA Travel Cover Demands & Needs and Terms of Business and agree to be bound by them unless I notify HASSRA Travel Cover of my wish to cancel the insurance within 14 days of receipt of my insurance documents.

Please note: If you don’t take reasonable care and the information you give is inaccurate or incomplete then we take one or more of the following actions:

Cancel your insurance;
Declare your membership void (treating your scheme membership and insurance as if it had never existed);
Change the terms of your insurance; or
Refuse to deal with all or part of any claim or reduce the amount of any claim payments.

We may ask you to provide further information and/or documentation to make sure that the information you gave us when taking out; making changes to or renewing your plan was accurate and complete. You are advised to keep a record of all information supplied in connection with this application, including any letters you send us.

Declaration Confirmation *

I have read and agree to the declaration outlined above

Future News & Offer Approval

Tick here if you would like to hear about special offers on other General Insurance products from CSIS

Instruction to your Bank or Building Society to pay by Direct Debit

Name(s) of Account Holder(s) *

Bank/Building Society Account Number: *

Branch Sort Code (without dashes): *

Name and full postal address of your Bank/Building Society

Name of your Bank/Building Society: *

Bank/Building Society Address: *

Instruction to your Bank or Building Society *

Please pay CSIS Travel Scheme Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with CSIS Travel Scheme and, if so, details will be passed electronically to my Bank/Building Society.

The Direct Debit Guarantee

This Guarantee is offered by all Banks and Building Societies that accept instructions to pay Direct Debits.
If there are any changes to the amount, date or frequency of your Direct Debit CSIS Travel Scheme will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request CSIS Travel Scheme to collect a payment, confirmation of the amount and date will be given to you at the time of the request.
If an error is made in the payment of your Direct Debit, by CSIS Travel Scheme or your Bank or Building Society, you are entitled to a full and immediate refund of the amount paid from your bank or building society. If you receive a refund you are not entitled to, you must pay it back when CSIS Travel Scheme asks you to.
You can cancel a Direct Debit at any time by simply contacting your Bank or Building Society. Written confirmation may be required. Please also notify us.

Quality cover while giving back

A reputation you can trust.

Don’t believe us? Just read through some of the many reviews we have from our HASSRA members.

Call our friendly sales team today on

01622 766960

or email us at hassratravel(at)csis.co.uk

Office Hours:

9.00am - 5:00pm Monday - Friday
Phone Hours:
9:00am - 4.00pm Monday - Friday

Company

HASSRA Travel Cover is a trading name of the Civil Service Insurance Society (CSIS), which is authorised and regulated by the Financial Conduct Authority (Firm Reference No. 304151).

The policy is distributed by CSIS and underwritten by Lloyd’s Syndicate 4444, managed by Canopius Managing Agents Limited. Canopius Managing Agents Limited is authorised by the Prudential Regulation Authority and regulated by both the Financial Conduct Authority and the Prudential Regulation Authority (Firm Reference No. 204847).

The travel scheme is provided by P J Hayman & Company Ltd, which is authorised and regulated by the Financial Conduct Authority (Firm Reference No. 497103).

Annual Travel Insurance Scheme Application Form

Lead Member Details

Cover Details

Data Protection Regulation - How your data is managed

Declaration

Instruction to your Bank or Building Society to pay by Direct Debit

The Direct Debit Guarantee

Quality cover while giving back

A reputation you can trust.

Call our friendly sales team today on

01622 766960

Office Hours:

Phone Hours:

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