Apply for personal accident, injury illness insurance

Application for personal accident, or accident and illness insurance

Before any question is answered read carefully the declaration at the end of this application, which must be agreed and dated. Every question must be answered fully and correctly by the person to be insured or on his behalf by the proposer

Accident and illness insurance application form
Name and details of insured
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).
Enter height in inches, for example, 5ft 6ins would be 5 x 12 + 6 = 66. Enter the value only (nothing else required) in the box above
Please enter you weight in pounds or kilograms (numbers only), and select the button above to indicate the measurement value chosen
Employment details
If more than one occupation, list all
Insurance period
Note: Cover cannot be backdated
Type of insurance
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.
Select an option from A or B, or choose one option from both A and B
*Capital benefits shall mean loss of Sight, Limb, Speech, Hearing and Permanent and Total Disablement
The sum insured is the amount of insurance cover you need - this will be the maximum liability of the underwriters
Benefits are payable for a maximum of 104 weeks
Benefits are payable for a maximum of 104 weeks for accident and a maximum of 52 weeks for illness
The sum insured - enter your net average weekly income into the box above
A few more questions
To the best of my / our knowledge and belief the information provided in connection with this application, whether in my / our own hand or not, is true and I / we have not withheld any material facts. I / we understand that non-disclosure or misrepresentation of a material fact may entitle the Underwriters to void the insurance. (NB. A material fact is one likely to influence acceptance or assessment of this application by the Underwriters. If you are in any doubt as to whether a fact is material or not, you must disclose it).
I/ we understand that the Underwriters will determine their terms and conditions upon the information provided in connection with this application; and I / we further understand that the signing of this application does not bind me / us to complete or the Underwriters to accept this Insurance.
It is understood by the Insured Person that any information about them will be processed by the Underwriters in compliance of the Data Protection Act 1998 and only for the purposes of providing their insurance cover and handling any claims. This may necessitate providing such information to third parties.
If you wish to submit this request it must be agreed to by all relevant parties below in order for it to be transmitted successfully
Thank you! The form was submitted successfully
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Need help?
If you would like to prefer to speak to a friendly advisors during business hours call: 01306 734100
You can contact us by e-mail if you wish to ask us any questions
Business hours
Monday - Friday 9.30 5pm
Closed weekends and Bank Holidays
Making a claim
If you would like to make a claim please send a message from contact us page, with your policy number and details of the claim.

We require all claims to be made in writing, we are not able to accept verbal claims by telephone
Important reading…
Key Facts and Policy wording can downloaded from the bottom of the page.

Accident & Illness Insurance Document Downloads

Key Facts Doc
Wording / Certificate