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Personal Accident Insurance Quotation

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.

 

Personal Accident/Sickness Insurance Quotation Form
Insured Details
Title: (i.e. Mr, Mrs, etc)
First name(s):
Surname:
Full address:
Full postcode:
Sex:  
Date of birth:
Height (in feet):

feet
Weight (in stones): stone
Are you resident in the UK for more than 6 months of the year?:    Yes No
Occupation and full nature of your business in which you are engaged:
Are you self employed?     Yes No
'IF YES'.  How long have you been self employed: years
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?: Yes No
Sickness Cover:  
General Information
Do you intend to travel frequently outside the UK during the next months?   Yes No
Did you undertake more than 10 flights as a fare paying customer in the past 12 months?   Yes No
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)?   Yes No
Scuba diving?   Yes No
Flying as a pilot?   Yes No
Hand-gliding or parachuting or other non-piloting aerial activities?   Yes No
Rock climbing or mountaineering?   Yes No
Participating in any sort of race or competition?   Yes No
Riding motorcycles or motor scooters?   Yes No
'If Yes' What is the largest CC bike you will ride?  C.C
Football and/or rugby?   Yes No
Any other occupation, sport, pastime or activity which is likely to involve extra risk of accident?   Yes No
Do you have any physical defect or infirmity or is your hearing or sight defective? (Ignore sight corrected by glasses or contact lenses)?   Yes No
Have you ever suffered from any disease or disorder of the heart, chest, bladder or any nervous or mental condition?   Yes No
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)?   Yes No
Are you currently taking and medication or do you have any medication prescribed?   Yes No
Have you undergone or have you reason to believe that you may need to undergo a surgical operation?   Yes No
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?   Yes No
Apart from any matter you have already described, are you now in and do you generally enjoy good health?   Yes No
Are you currently insured against accident and sickness?   Yes No
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?   Yes No

Claims
Have you ever submitted a personal accident/sickness claim or is there any such claim pending?   Yes No
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):
Renewal/Target premium:
Contact name:
Email address:   
Telephone number:   
Preferred choice of quotation contact:  
Preferred payment method:   
 

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


 



GJT Hodgson Insurance Services are authorised and regulated by the Financial Services Authority.

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