Personal Accident Insurance Quote Form

Insured Details

Title:

First name(s):

Surname:

Full address:

Full Postcode:

Sex:

Date of birth:

Height (in feet):

Weight (in stones):

Are you resident in the UK for more than 6 months of the year?:

YesNo

Occupation and full nature of your business in which you are engaged:

Are you self employed?

YesNo

IF YES How long have you been self employed:

What is your gross income?: £

Cover Details

Policy Period

Please Indicate Which Of The Following Cover Options You Require:

Accidental Death. Gives you a lump sum to your family in event of your accidental death.
Capital Benefits. Gives you compensation in event of you losing a limb or eyesight.
Temporary Partial Disablement. If you can't undertake a substantial part of your normal business duties.
Weekly Benefit. This is how much a week you wish to receive back after being off work through an accident or sickness.
Sickness Cover. You can extend the accident cover to include cover against you being ill or sick for an additional premium.

Accidental Death Cover:

Capital Benefits Cover:

'Temporary Total Disablement' Weekly Benefit For An Accident (Up to 75% of your average weekly income):

Temporary Partial Disablement Cover required?:

YesNo

Sex:

General Information

Do you intend to travel frequently outside the UK during the next months?

YesNo

Did you undertake more than 10 flights as a fare paying customer in the past 12 months?

YesNo

Do you wish to be covered for the following risks which are NOT covered unless specifically agreed and endorsed on your certificate, please tick 'yes' if required.

Winter sports (only non-competitive activities will be considered for cover)?

YesNo

Scuba diving?

YesNo

Flying as a pilot?

YesNo

Hand-gliding or parachuting or other non-piloting aerial activities?

YesNo

Rock climbing or mountaineering?

YesNo

Participating in any sort of race or competition?

YesNo

Riding motorcycles or motor scooters?

YesNo

'If Yes' What is the largest CC bike you will ride? (C.C)

Football and/or rugby?

YesNo

Any other occupation, sport, pastime or activity which is likely to involve extra risk of accident?

YesNo

Do you have any physical defect or infirmity or is your hearing or sight defective? (Ignore sight corrected by glasses or contact lenses)?

YesNo

Have you ever suffered from any disease or disorder of the heart, chest, bladder or any nervous or mental condition?

YesNo

Have you ever suffered from or do you suffer from cancer, tuberculosis, diabetes, varicose veins, sciatica or other similar illness, back or spinal problems (e.g, slipped disc, repetitive strain injury (RSI), epilepsy, hernia, high blood pressure, etc)?

YesNo

Are you currently taking and medication or do you have any medication prescribed?

YesNo

Have you undergone or have you reason to believe that you may need to undergo a surgical operation?

YesNo

Have any accidents or illnesses prevented you from attending to your business or occupation for periods of more than 14 days during the past 3 years?

YesNo

Apart from any matter you have already described, are you now in and do you generally enjoy good health?

YesNo

Are you currently insured against accident and sickness?

YesNo

Have you ever been declined or accepted on special terms for life, accident or sickness insurance, or have Lloyds underwriters or any company ever cancelled or declined to renew your policy?

YesNo

Claims

Have you ever submitted a personal accident/sickness claim or is there any such claim pending?

YesNo

IF you have answered 'YES' to any questions in the 'General Information' section, or you have any other material facts, please explain your answer in full here:

Contact Information

Renewal/Inception date:

Current insurers (If applicable):

Target/Renewal premium: £

Contact Name:

Email address:

Telehone number:

How to contact you:

Preferred payment method:

Please now submit the personal accident insurance quotation form through to our office to arrange your quote.

Personal Accident Insurance Quotation

Insured Details

Cover Details

General Information

Contact Information

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