Accident
& Sickness Insurance - Quotation Request
Your Name
E-mail address
Postal Address
Postcode
Telephone No
The
Insured
Name
Date of birth
Occupation
Please insert full details of manual duties (if
any)
Medical
Information
Has the insured person ever been diagnosed as suffering from
any of the following?
Heart trouble, high blood pressure, circulatory problems,
tuberculosis, chest or lung problems, back disorders/problems, complaints
of the digestive system, nervous/anxiety problems, diabetes, any
other sickness or recurring complaint
if yes, please give details
Has the insured person consulted any doctor or received any
medical attention or advice in the last three years?
Other
Information
Has the Insured Person ever been declined or charged extra premium
for any accident, sickness or life insurance in the past
Does the insured person participate in any hazardous pursuit,
activity or sport, or reside or travel extensively outside the
UK
If you have answered yes to either of the above questions please
give full details below
Schedule
of Compensation
Please
insert the sums to be insured for the following:- (please
note that benefits 8 & 9 must not exceed 75% of gross income
(including all other insurance benefits and payments received
from an employer), if benefits are payable to an individual.
1. Death due to accident
2. Loss of limb by one accident
3. Total and irrecoverable loss of sight of one eye by accident
4. Loss of two limbs by accident
5. Total and irrecoverable loss of sight of both eyes by accident
6. Loss of one limb and total irrecoverable loss of sight of
one eye by accident
7. Permanent total disablement by accident
8. Total disablement by accident (per week)
deferment period (min 2 weeks)
benefit period (max 104 weeks)
9. Total disablement by accident and illness (per week)
deferment period (min 2 weeks)
benefit period (max 104 weeks)
10. Permanent total disablement by accident and illness
Insurance required from
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Cheque
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