Tree Surgery Insurance, Arboricultural Insurance, Tree Surgeon Liability Insurance, Commercial Vehicle Insurance, Fleet Insurance

Arborists Personal Accident Insurance

The completion of this form in no way binds the Proposer to purchase insurance, nor does it bind Underwriters to give insurance.

Any information given will only be passed to Underwriters for the purpose of quotation and will be treated as confidential.

Name

Telephone Number:

Address

Postcode:

Email Address

Date of Birth

National Insurance Number

Height

Weight

Occupation

Is Manual Work involved

Yes	No

Are you self employed

Yes	No

Requested Period of insurance

From

Have you ever had any physical defect or infirmity such as high blood pressure, a heart condition, haemorrhoids, varicose veins or other circulatory disorder or diabetes, a "slipped disc", lower back strain or other spinal disorder, a hernia or any rheumatic or arthritic condition, asthma, bronchitis or any chronic respiratory disorder, or any other condition or injury needing medical advice or treatment in the past three years, or that may require future treatment?

Yes	No

Details

Do you intend or anticipate that you might:

Travel extensively or reside temporarily outside the United Kingdom?

Yes	No

Undertake more than 20 air flights per annum or fly other than as a fare paying passenger

Yes	No

If yes please provide full details including expected number of flights

Ride motorcycles or motor scooters

Yes	No

If yes please advise cc

engage in football, rugby, equestrian or winter sports, or any other sport(s), pastime(s) or activity(ies) likely to involve extra risk of accident

Yes	No

Details

Are there any additional facts affecting the proposed insurance which should be disclosed to underwriters.

Apart from any matter you have already described, are you in and do you generally enjoy good health

Yes	No

If no please provide details

Have you ever been declined or been accepted on special terms for life, accident, illness, medical, travel or any other health related insurance?

Yes	No

If no please provide details

Please specifiy amount of cover required
Death
Loss of a limb
Loss of sight
Permanent total disability
Temporary total disability
Temporary Partial disability
Extra Benefit: Medical Expenses The insurance includes medical expenses arising from insured events 5 and 6 of section A and insured event 3 of Section B, up to 15% of any claim that we pay for that insured event.
Notes applicable to insured events and sums insured: This insurance contains a restriction linked to your average earnings in respect of the maximum amount payable for temporary total disability and temporary partial disability (insured events 5 & 6 of section A and insured event 3 of section B. Please refer to your insurance adviser for further details. Temporary partial disability cover is only available to person in non-manual occupations.

Declaration I/We declare that to the best of my/our knowledge and believe all the information given on this proposal is true and complete and that nothing which might influence the underwriters in accepting or assessing this proposal has been withheld. I/We also declare that if any details or answers on this form have been computer generated or written by another person that person has acted as my/our agent. I/We hereby consent to any information that you may have about me/us being processed by you for the purpose of providing insurance and claims handling which may necessitate your providing such information to third parties.

Personal Accident Insurance, Self Employed Liability Insurance, Shops And Offices Insurance, Commercial Insurance, Marine Insurance - Trust Insurance

Home page :: About Trust Insurance :: Tree Surgery Liability :: Fleets :: Tools / Engineering :: Professional Indemnity :: Personal Accident :: Self Employed Liability :: Shops and Offices :: Commercial Insurance :: Marine Insurance :: Close Protection :: Contact :: Links :: Motor Insurance :: Legal Protection ::
How to make a claim :: Terms of Business