Personal Accident Insurance Proposal Form


Here is a brief summary of the cover provided by our Personal policy. We will be pleased to discuss the details of the cover that is best suited to your needs, and will supply a specimen policy which sets out the full terms and conditions in details which alone will govern any contract of insurance.

The Cover

The different sections of the policy provided you with compensation for various forms of bodily injury resulting from and accident and becoming apparent within 12 months of the accident. You can choose the section or sections which best provide you with the protection you need. However, to be covered under sections 4 or 5 you will also need to be covered under sections 1,2 or 3.

Section 1 – Death

Section 2 – Restricted Permanent Disablement

This covers you for the following injuries: -

  • Loss of two or more limbs, or
  • Loss of both eyes, or
  • Loss of one limb and one eye, or
  • Permanent Total Disablement

Section 3 – Full Permanent Disablement

This provides rather more extensive cover than section 2.

You receive varying percentages of the compensation you have chosen depending on the severity of your disability. The actual amounts paid are calculated from the following table: -

Percentage of compensation selected
Permanent Total Disablement   100
Loss of both eyes   100
Loss of two limbs 100
Loss of one limb together with one eye 100
Complete incurable insanity  100
Loss of one limb     50
Compete loss of hearing in both ears 50
Loss of one eye 40
Complete loss of speech   40
Loss of thumb of right hand  20
Loss of thumb of left hand  15
Loss of index finger of right hand 15
Loss of index finger or left hand  10
Complete loss of hearing in one ear   10
Loss of one big toe 10
Loss of any finger or toe not otherwise specified   3

Other disabilities are also covered and payment will be made depending on their degree of severity as compared with the disabilities shown in the above table.

Although you can receive payment in respect of more than one disability, the maximum payment will be limited to 100% of the compensation you have chosen.

Cover for loss of a limit includes loss of use as well as actual physical loss.

If you are left handed, any reference above to ‘right’ shall be interpreted as ‘left’, and vice versa.

Section 4 – Temporary Disablement           

A weekly income is provided if you are totally disabled and unable to carry out your normally work. The money is normally paid as a lump sum when you return to work but we can pay every 4 weeks in arrears during your disability, if you prefer.It is payable for maximum of 104 weeks.

Section 5 – Medical Expenses
This covers you for any medical expenses you may incur as a result of the accident, upto the maximum compensation you have chosen, provided that a claim is respect of the same injuries is accepted under another section of your policy.

Main exceptions

The main exceptions in your policy excludes accident, upto the maximum compensation you have chosen, provided that a claim of these risks at an extra charge:

Parachuting, mountaineering, caving, winter sports, ice hockey, use of underwater breathing apparatus, water skiing, speed-boating, ocean sailing, deep-sea fishing, hunting, show jumping, steeple chasing, polo, rugby football, motor cycling as driver or passenger, racing or any practice for racing (other than on foot), undertaking any other abnormally hazardous pursuits, using power-driven woodworking machinery (Other than portable hand-tools used for private purposes), aviation (except as a passenger in a fully licensed aircraft), insanity, intoxication, drugs, childbirth, pregnancy, suicide intentional self-injury, pre-existing mental or physical condition, war and similar perils, nuclear radiation.

The Cost

For an indication of the cost, simply: -

1) Select from the list below the occupational class, which applies to you.

2) Decide the benefits you need, and the amount under each section

Then calculate your premium from the table below.

Classification of Occupations:

Class 1 –

Those engaged solely in professional, administrative or clerical duties.

Class 2 –

Those engaged in industry who do not use machinery or tools and do not engage in heavy manual work; shop-keepers (other than butchers and fishmongers or those using tools); commercial travellers.

Class 3 –

Those engaged in an occupation not otherwise classified and not being a hazardous occupation.

Hazardous –

Those engaged in a hazardous occupation or who use power-driven woodworking or other dangerous machinery.

Section Result Of Bodily Injury Compensation in Currency Units Annual Premiums
Class 1 Class 2 Class 3 Hazardous
1 Death Per 1000 0.90 1.20 1.60 Will be considered on application
2 Restricted Permanent Disablement Per 1000 0.15 0.25 0.45
3 Full Permanent Disablement Per 1000 0.85 1.20 1.70
4 Temporary Total Disablement Per 10 per week 2.15 3.20 4.30
5 Medical Expenses Per 100 per accident 2.15 2.70 3.75

i. Whilst in some circumstances adjustments may be necessary, the rates shown will normally apply if you are aged between 16 and 65 years.

ii.Remember that you can only be covered under sections 4 and / or 5 provided you are covered under at least one of sections 1,2 or 3.

iii.If you do not need the income under section 4 to be paid as soon as you stop work, we will reduce the premium for this section depending on the period excluded.

Period Excluded Discount
2 weeks  20%
4 weeks   35%
8 weeks   45%
Proposal Form - Personal Accident Insurance
Please select the country/city where the form is to be submitted
1 Insured Name
2 Address
3 Telephone No:
4 Fax No:
5 E-mail
Details of person to be insured (if different from proposer above)
Name Address
N.B. Where the person to be insured is not the Proposer, all personal details must be completed by the person to be insured, and the Declaration must be signed by both the Proposer and the person to be insured.
Occupation (Please give full details):
Professional, administrative or clerical only
Supervising only
Working manually without machinery
Using machinery
Date of Birth
Period of Insurance : From To (both dates inclusive)
1.(a) Height
   (b) Weight
2. Have you consulted a doctor or medical attendant in connection with illness or accident during the last 5 years?


If 'YES' give full details?



3. Have you ever suffered from any infection of the eyes, ears, heart from fits, paralysis, slipped disc or any other disorder of the back, nervous disorders, varicose veins, rupture or any other mental or physical infirmity or defect.

If 'YES' give full details?




4. Are you now in sound health and free from all physical defects or infirmities?


If 'NO' give full details?

5 .Are there any circumstances connected with your occupation, habits or pursuits, which render you specially liable o accidents?


If 'YES' give full details?


6. Do you drive, or travel by, any motor Vehicle (other than a public transport vehicle) in connection with your occupation during working hours?


If 'YES' give full details?



7. Are you now insured or proposing to effect further insurance against Personal Accident with this or any other Insurer?


If 'YES' give full details?



8. Have you ever had a Personal Accident, sickness or Life Assurance declined, terminated or subjected to special terms by an Insurer?


If 'YES' give full details?




9. Result of Bodily Injury
(Please see Definitions of cover attached)
Compensation selected Premium
  Section 1 - Death
  Section 2 -Restricted Permanent Disablement
  OR    
  Section 3 - Full permanent Disablement
  Section 4 - Temporary Total Disablement
  Section 5 - Medical Expenses a maximum of
10. Under Section 4 do you wish to exclude payment by the Insurer for an initial period of disablement?
If 'YES', please insert the number of weeks (2,4 or 8) weeks
Less % discount
Total

Inflation Safeguard Option
This option is designed to help you to maintain adequate compensation levels during the current inflationary times. If you decide to take up this option we simply increase all benefits by 10% automatically at each renewal and adjust your premium by the same proportion.
Would you like this extra benefit?

Declaration


I/We declare that the answers given in the Proposal are true to best of my/our knowledge and I/We have withheld no information whatever which might influence the decision of the Insurer regarding the Proposal.

I/We agree that the Proposal shall be incorporated in and shall form the basis of the contract between the proposer and the Insurer and a Policy in the form issued by the Insurer for the insurance now poposed acceptable.

I/We agree to inform the Insurer of any material change in risk.
N.B Cover does not commence until the Proposal is accepted by the Insurer and the first premium paid.
 

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