Group Personal Accident Insurance Facility

Broker/Intermediaries Name

Broker/Intermediaries Email

Telephone No.

Fax No.

Please answer the following questions Yes or No and give details where applicable below

Cover Required:
Personal Accident only YES NO
Personal Accident & Illness Benefit YES NO

Period of Cover:
24 Hour YES NO
Business duties/affinity group participation only YES NO

Amount of Benefits Required:

Deferment period (number of days/weeks)
(If quotations are required for various levels of benefits please continue overleaf)

Claims History: (if insufficient space please continue overleaf)

E-mail / fax / or post this form.