Accident & Sickness Insurance - Quotation Request

Your Name

E-mail address

Postal Address

Postcode

Telephone No

Are you an existing Rowett Insurance client?

  Yes

  No

The Insured

Name

Date of birth

Height

select >>> feet/inches metres/centimetres  

Weight

select >>> stones/pounds kilos  

Occupation

Please insert full details of manual duties (if any)

Medical Information

Has the insured person ever been diagnosed as suffering from any of the following?

a) Heart trouble

  Yes

  No

b) High blood pressure

  Yes

  No

c) Circulatory problems

  Yes

  No

d) Tuberculosis, chest or lung problems

  Yes

  No

e) Back disorders/problems

  Yes

  No

f) Complaints of the digestive system

  Yes

  No

g) Nervous/anxiety problems

  Yes

  No

h) Diabetes

  Yes

  No

i) Any other sickness or recurring complaint

  Yes

  No

j) Has the insured person consulted any doctor or received any medical attention or advice in the last three years?

  Yes

  No

If you have answered yes to any of the medical questions above please give full medical details here

Other Information

Has the Insured Person ever been declined or charged extra premium for any accident, sickness or life insurance in the past

  Yes

  No

Does the insured person participate in any hazardous pursuit, activity or sport, or reside or travel extensively outside the UK

  Yes

  No

If you have answered yes to either of the above questions please give full details below

Schedule of Compensation

Please insert the sums to be insured for the following:-
(please note that benefits 8 & 9 must not exceed 75% of gross income (including all other insurance benefits and payments  received from an employer), if benefits are payable to an individual.

1. Death due to accident

2. Loss of limb by one accident

3. Total and irrecoverable loss of sight of one eye by accident

4. Loss of two limbs by accident

5. Total and irrecoverable loss of sight of both eyes by accident

6. Loss of one limb and total irrecoverable loss of sight of one eye by accident

7. Permanent total disablement by accident

8. Total disablement by accident (per week)

deferment period (min 2 weeks)

 weeks

benefit period (max 104 weeks)

 weeks

9. Total disablement by accident and illness (per week)

deferment period (min 2 weeks)

 weeks

benefit period (max 104 weeks)

 weeks

10. Permanent total disablement by accident and illness

Insurance required from

Preferred Payment Method

choose >>> Credit Card Debit Card Cheque Direct Debit