Accident and illness insurance application form
Who is the insurance for?
Name and details of insured
Date of Birth* (dd/mm/yyyy):
Your Address - House / Street*:
Town / City*:
Additional details of insured
Please provide the height and weight of the insured. Enter height in inches, numbers only, for example 5ft 6ins (5 x 12 + 6) would be entered as 66 in the height box below. For weight enter the value in pounds or kilograms then indicate what the value represents by selecting the appropriate button.
For example someone 10 st 5 lbs would enter 145 (10 x 14 + 5 = 145).
Occupation of insured*:
If more than one occupation, list all
Is manual work involved?*
Select YES or NO...
Yes - manual work is involved
No manual work is involved
Employment status of insured?
Select full time/part time or Self employed
Full time/part time employment
Our Accident and illness policy is flexible, start by selecting one option from
A, enter the sum insured, this is the amount insurance cover you require, this will be the maximum payout of the policy. You can choose one of the additional benefits from section B, enter your average weekly income into the sum assured box. Documentation is available at the bottom of this page for further policy details.
A few more questions
Do you (or the insured) intend to travel outside of Europe, North America, Canada, Australia or New Zealand in connection with your business or occupation?
Do you (or the insured) wish to be covered whilst participating in football, rugby or any other sport, pastime or activity that is likely to involve extra risk of an accident? (If in any doubt please ask your agent for advice)
Are you (or the insured) currently insured against accident or illness?
Does the total weekly benefit under all insurances carried by you (or the insured), including that now applied for, exceed average net weekly income?
Have you (or the insured) ever been declined or accepted on special terms, for life, accident, or illness insurance, or has any insurer ever cancelled or declined to renew your insurance?