PERSONAL ACCIDENT & SICKNESS INSURANCE

Proposer's Name

E-mail address (required)

Address

Postcode

Telephone No

Contact Name

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)

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

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

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

email validation

Due to the amount of SPAM email we recieve please enter the code that you see in the box below to validate this as a genuine quote request... sorry but we have to ask you to do this due to the amount of spam that we receive...