This field is hidden when viewing the formPolicyName & Surname(Required) Name Surname ID or Passport Number(Required)Email(Required) Enter Email Confirm Email Reason for opting not to take the coverConsent(Required) I agree and acknowledge that I am aware that by opting not to take cover as part of the current offering available to all employees of my employer that I will not be eligible to claim against any of the insurance benefits offered by the Cinagi Gap Cover Policy and will be fully underwritten should I opt to join at a later stage.Signature(Required) Δ