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Personal Accident and Sickness insurance provides a short term (up to two years) solution to reductions in your income as a result of accident or sickness.
Premiums are quoted on an annual basis, and cover will be subject to an excess
period of usually 14 or 21 days of inability to work.
If you require more specific
benefits than are available here please contact our offices on 0845 838 7960.
Please submit your details for a no obligation
quotation for personal accident and sickness insurance.
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Personal Accident and
Sickness Insurance Quote |
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Name |
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Email |
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Address |
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Postcode |
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Telephone |
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Mobile |
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Date of Birth |
dd/mm/yyyy |
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Occupation |
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Duties performed |
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Employment Status |
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If self
employed for less than a year previous occupation |
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Cover
Required |
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Sum Payable in respect of Death,
Loos of Sight, Loss of Limb or Permanent Total Disablement |
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Weekly Benefits Payable in
respect of Temporary Total Disablement |
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Net weekly pay |
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Gross weekly pay |
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Do you travel outside Europe? |
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if "Yes" please state likely countries. |
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Do you wish to be covered for the following risks; |
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Winter Sports |
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Skin/Scuba Diving |
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Rock Climbing |
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Potholing |
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Hang Gliding or Parachuting |
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Hunting on Horseback |
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Competitive Driving |
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Riding Motorcycles |
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Air Travel Other than as a passenger |
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Football |
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Rugby |
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Dangerous Pastimes |
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details |
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Defective hearing or vision |
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details |
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Have you ever suffered from hernia, lower back strain, disc lesion or
any other physical defect of a chronic or recurring nature? |
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details |
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Have you ever suffered from any heart condition, hypertensions, varicose veins, nervous condition, alcoholism, drug addiction or other illness, weakness of a chronic or recurring nature.? |
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details |
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Have you undergone, or do you have any reason to believe you may need to
undergo a surgical operation?please give details |
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What accidents or illness have prevented you from working for a period
of more than 14 days in the last three years?
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Are you generally in good health? |
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Have you ever had special terms imposed on you, or had any insurance
cancelled by any insurer? |
details |
