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Home » Commercial Insurance » Quotes and Forms » Forms
  PROPOSAL FOR PERSONAL ACCIDENT INSURANCE  
     
 

PLEASE NOTE: An agent who completes a Proposal Form does so as an agent of the proposer.

It is essential that every question with * be answered fully for proper processing of the form.

1.
(a)  Proposer
Agent Individual
  TITLE  
  Surname *  
  First Name *  
  Other Names  
  Maiden Name  
         
(b) Full Postal Address *
(to which all correspondence would be sent)		  
  Tel. No. *  
         
  Permanent Address  
  Tel. No.  
         
(c) Occupation
(Pls give full details)		  
  Fax. No.  
  E-mail Address *  
         
(d) Date of Birth
Day   Month  Year
 
         
(e) Nationality
  
         
(f) Marital Status
Married Single Divorced Widow
 
         
2.
(a)
Height (in meters) Weight (in kilograms)
3.
(a) Name of Hospital
  Address of Hospital
(b) Please give details of accidents or illness you have consulted a Medical Doctor for in the last 10 years and dates.
4.
Have you
(a) any physical defect or infirmity?
(b) ill-health of any description?
if so, please give details
5.
Do you normally enjoy good health?
6.
(a) Do you use a motor vehicle for traveling to and from your place of business?
(b) Does your occupation otherwise require you to travel widely or regularly? Please describe fully.
7.
Do you engage in
(a) any of the physical activities listed in Exception (c) below?
(b) any other hazardous activities? If so, please give details
8.
Are there any circumstances connected with your occupation, health, pursuits or habits of life which render you particularly liable to injury or ill health? if so, please give details.
(Note: if you wish to be covered whilst engaged in any such activities, special application must be made)
9.
To what extent will you travel by recognized airline?
10.
(a) Are you presently insured against accidents? If so, state name of Insurer and the benefits provided
11.
(a) State benefits now required: A,B,C,D & amount Selected
  Per week
A.
B.
C.
D.
  Do you require the policy extended to include:  
  (a) Motor cycling
  (b) Hunting
  (c) SRCC
  (d) Winter Sports
  (e) Any other special feature

Exceptions
No payment will be made for death, disablement or expenses resulting from
(a) injury sustained whilst under the influence of intoxicants or drugs or whilst suffering from venereal disease or insanity
(b) willful exposure to peril (except in attempt to save human life) or criminal act.
(c) mountaineering necessitating the use of ropes or guides, pot-holing, parachuting, skin-diving, winter sports, racing of any kind other than on foot, hunting other than on foot, steeple chasing, football, polo or the use of a motor cycle, motor scooter, moped or mechanically-assisted pedal cycle.
(d) medical or surgical treatment except where rendered necessary by injury within the scope of the policy.
(e) flying other than as a fare-paying passenger
(f) in the case of a female, pregnancy or childbirth
(g)

war or kindred risks, riot or civil commotion
(h) riding on motorcycle whether as a rider or passenger
(i) military or paramilitary exercises
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