Personal Accident, Illness & Redundancy Insurance

Personal Accident Insurance with Optional Illness & Redundancy Benefits. Available to U.K. Residents Only.

Please answer the following questions Yes or No and give details where applicable below.

1. Is there any manual work involved in your occupational duties? Yes No

2. Have you any physical defect or infirmity, or any defect of your sight or hearing or other senses or faculties? Yes No

3. Have you ever suffered from any of the following:

(a) Clinical depression, or anxiety, or any nervous, or mental condition, fainting episode, blackouts, fit or paralysis of any kind? Yes No

(b) High blood pressure, a heart condition, haemorrhoids, varicose veins, or other circulatory disorder, rheumatic fever, or diabetes? Yes No

(c) a "slipped disc" or other spinal disorder, a hernia, or any rheumatic or arthritic condition? Yes No

(d) Any respiratory, urinary, or allergic condition, or any disorder of the digestive system? Yes No

(e) Any other condition or injury needing medical advice or treatment in the past five years, or any symptom or tendency that might necessitate this in the future? Yes No

4. Have you ever been declined or accepted on special terms for life, accident or illness insurance? Yes No

5. Have you ever received counselling or any medical advice, test or treatment in connection with A.I.D.S. or any A.I.D.S. related condition? Yes No

6. Do the weekly benefits under all insurance carried by you, including those that are applied for in this proposal, exceed your average weekly net earnings? Yes No

7. Do you anticipate that you might:

(a) Travel extensively or reside temporarily outside the United Kingdom? Yes No

(b) Undertake more than 20 air flights per annum, or fly other than as a fare-paying passenger? If so please state full details and expected number of flights. Yes No

(c) Engage in football, rugby, equestrian or winter sports, or any other sports or pastimes rendering you liable to personal injury? Yes No

8. Are there any additional facts affecting the proposed insurance, which should be disclosed to the Underwriters?

9. Redundancy Benefit: This cover is only available to those persons who have been continuously employed by the same employer for a minimum period of 2 years. If you qualify and require cover please complete the following:

10. Have you smoked within the last 24 months Yes No

Select the amount of Benefit required

Not sure what benefits you require? phone us on 020 7739 3444 and we will endeavour to guide you