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Personal Accident Insurance Quotation

If you are looking for a personal accident/sickness insurance quotation, please fully check and 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:
Postcode:
Sex:  
Date of birth:
Height (in metres):

metres

Weight (in kilograms): kilograms
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 the date you would like cover to commence should your proposal be accepted

Please Indicate Which Of The Following Cover Options You Require
Accidental Death Only   Yes No
Accidental Death and Capital Benefits   Yes No
Temporary Total Disablement Per Week   Yes No
How much 'per week' benefit cover do you require? (You can insure for up to 60% of your average gross weekly wage, and you can insure in blocks of 50, i.e. 100, 150, 200 etc) a week back
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
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.


 

 

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