Name							Email
Address
Postcode
Telephone							Mobile
Date of Birth				dd/mm/yyyy
Occupation					Duties performed
Employment Status				Choose Employed Self Employed less than a year Self Employed Less than two years Self Employed more than two years			If self employed for less than a year previous occupation
Cover Required				Choose Personal Accident and Illness Personal Accident Only			HeightFt/in Weight lbs
Sum Payable in respect of Death, Loss of Sight, Loss of Limb or Permanent Total Disablement				Choose Nil £10,000 £20,000 £30,000 £40,000 £50,000 £60,000 £75,000 £100,000			Weekly Benefits Payable in respect of Temporary Total Disablement		Choose Nil £50 Per Week £100 Per Week £200 per week £300 per week £400 per week £500 per week
Net weekly pay							Gross weekly pay
Do you travel outside Europe?				Choose No Yes			if "Yes" please state likely countries.
Do you wish to be covered for the following risks;							Winter Sports		Choose Yes No
Skin/Scuba Diving				Choose Yes No			Rock Climbing		Choose Yes No
Potholing				Choose Yes No			Hang Gliding or Parachuting		Choose Yes No
Hunting on Horseback				Choose Yes No			Competitive Driving		Choose Yes No
Riding Motorcycles				Choose Yes No			Air Travel Other than as a passenger		Choose Yes No
Football				Choose Yes No			Rugby		Choose Yes No
Dangerous Pastimes				Choose Yes No			details
Defective hearing or vision				Choose Yes No			details
Have you ever suffered from hernia, lower back strain, disc lesion or any other physical defect of  a chronic or recurring nature?									Choose Yes No
details
Have you ever suffered from any heart condition, hypertensions, varicose veins, nervous condition, alcoholism, drug addiction or other illness, weakness of a chronic or recurring nature.?								Choose Yes No
details
Have you undergone, or do you have any reason to believe you may need to undergo a surgical operation? Choose Yes No please give details
What accidents or illness have prevented you from working for a period of more than 14 days in the last three years?
Are you generally in good health?						Choose Yes No
Have you ever had special terms imposed on you, or had any insurance cancelled by any insurer?						Choose Yes No details