BusinessInsuranceQuotations.com Personal Accident and Illness Proposal Form 1. Your Name (details of insured person): 2. Your Address:  Post Code:            Date of Birth:  Telephone Number:  E-mail address: 3. Occupation:  Please provide details of any work outside the UK 4. Accident Benefits  SUMS INSURED (maximum 75% of weekly wage)  Death/eyes/limbs/Permanent Total Disablement: £  Temporary Total Disablement (Weekly):  (Benefit period 104 weeks) £ per week  Illness Benefit (if required)  Permanent and total loss of sight in one or both eyes: £  Permanent total disablement by paralysis: £  Temporary Total Disablement (Weekly):  (Benefit period 52 weeks) £ per week  Loss of Liquor Licence: (Enter the value of business that would be lost if your alcohol licence was refused or revoked) £ 5. Lifestyle - if you answer yes to any of the following, please give full details below. Do you take part or practice any of the following -  Sports or hazardous pastimes?  Yes No  Flights by private planes?  Yes No  Travel or reside outside the EU?  Yes No  Have you ever suffered from any medical condition, been asked to invesigate any medical condition, or awaiting results of any medical condition?  Yes No  Have you ever been declined insurance, been deferred or accepted on special terms?  Yes No If any of the previous answers was Yes, please give details 6. Current Insurance    Name of current insurers (so that we don't approach them!)  Expiry date of current insurance  Current premium (if known) £ Please supply me with an estimate within 105 working days. (We will attempt to meet the target, but please be aware that it does require our insurers to respond quickly as well!) Done   Please check your details, and when you are happy that all is correct, tick the 'Done' box and then click the Submit button above...