Your Coverwise Travel Policy Medical Declaration

Reference number: CW-25598901/2 Date: 08/08/2017 Policy number: 25598901

Thank you for purchasing your travel insurance policy with Coverwise. We have offered a quotation and issued a policy on the under-
standing that at the time of purchasing this insurance you are fit to travel and are not currently suffering a decline in health that
could reasonably cause you to cancel a trip or make a claim. Additionally, that you have declared all pre-existing medical conditions
relevant to the questions that were asked through the booking process, whether on line or through the call centre, and that all the
answers given in relation to the specific medical conditions that you have declared are accurate.
It is important that you are aware that we do not offer the option of partial cover, as this will not allow us to adequately assess your
health risk from an insurance perspective.
Telling us about some but not all of your pre-existing medical conditions may result in us not collecting the correct premium to cover
you as an individual for health related claims; this may also result in us issuing a policy where, had we been informed of all the facts,
we would not have offered a policy at all.
For this reason claims related to non-disclosed pre-existing medical conditions will not be paid and claims relating to declared medical
conditions or new medical conditions, may be proportionately reduced or declined in full if we establish that you have told us about
some, but not all your pre-existing medical conditions or provided us with inaccurate information.
This document records the medical conditions that you have told us about, to ensure that you are properly protected in the event of
a health related claim, please carefully review the declaration below and contact us immediately if the declaration is either incomplete
or inaccurate.

Personal Details: https://www.coverwise.co.uk

12/08/2017 to 26/08/2017 Platinum Select Europe (includes all

Name: Miss Tilly O'Rourke Date of birth: 14/07/2005

Declared Medical Conditions:

Medical Condition: Date of screening: Status:
08/08/2017 Covered
--Condition: Bronchomalacia
Has this been surgically corrected with no ongoing breathing problems? - Yes

How many unplanned hospital admissions have you had for this condition in the last twelve months? - None

--Condition: Dwarfism
Do you suffer from back pain? - No

0.00 V1-12/15