If you are looking for a
personal accident/sickness insurance quotation, please fully complete the quotation form below. A personal accident insurance
policy helps provide financial help in the event you have an accident or
illness which keeps you off work for a period of time. For a cheap accident and
sickness insurance quotation simply complete the quotation form
below and submit it to us. We will then contact you as soon as
possible with a quotation. Alternatively, please contact our
office on 01288 353999 where we will be more than pleased to assist you
over the phone.
Insurance Quotation Form
Title: (i.e. Mr, Mrs, etc)
Date of birth:
Height (in feet):
Weight (in stones):
Are you resident in the UK for more
than 6 months of the year?:
Occupation and full nature of your
business in which you are engaged:
Are you self employed?
'IF YES'. How long have
you been self employed:
What is your gross income?:
Please select period >
Gives you a lump sum to your family in event of
your accidental death. Please Indicate Which Of The Following
Cover Options You Require:
Accidental Death. Gives you compensation in event of you losing a
limb or eyesight.
Capital Benefits. If you can't undertake a substantial
part of your normal business duties.
Temporary Partial Disablement. 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:
Nil, Not Required
Capital Benefits Cover:
Nil, Not Required
'Temporary Total Disablement' Weekly
Benefit For An Accident (Up to 75% of your average weekly income):
£ 50 a week
£ 100 a week
£ 150 a week
£ 200 a week
£ 250 a week
£ 300 a week
£ 350 a week
£ 400 a week
£ 450 a week
£ 500 a week
Temporary Partial Disablement Cover
Yes. Same weekly benefit as accident cover.
Do you intend to travel frequently outside
the UK during the next months?
Did you undertake more than 10 flights as a
fare paying customer in the past 12 months?
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)?
Flying as a pilot?
Hand-gliding or parachuting or other
non-piloting aerial activities?
Rock climbing or mountaineering?
Participating in any sort of race or
Riding motorcycles or motor scooters?
'If Yes' What is the largest CC bike
you will ride?
Football and/or rugby?
Any other occupation, sport, pastime or
activity which is likely to involve extra risk of accident?
Do you have any physical defect or infirmity
or is your hearing or sight defective? (Ignore sight corrected by
glasses or contact lenses)?
Have you ever suffered from any disease or
disorder of the heart, chest, bladder or any nervous or mental
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)?
Are you currently taking and medication or
do you have any medication prescribed?
Have you undergone or have you reason to
believe that you may need to undergo a surgical operation?
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?
Apart from any matter you have already
described, are you now in and do you generally enjoy good health?
Are you currently insured against accident
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
Have you ever submitted a personal
accident/sickness claim or is there any such claim pending?
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:
Current insurers (If
Preferred choice of quotation
Any Of The Above
Preferred payment method:
Please now submit the
personal accident insurance quotation form through to our office to
arrange your quote .