Please answer the following questions Yes or No and give details where applicable below
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1. Is there any manual work involved in your occupational duties?
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YES NO
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2. Have you any physical defect or infirmity, or any defect of your sight or hearing or other senses or faculties?
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YES NO
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3. Have you ever suffered from any of the following:
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(a) Clinical depression, or anxiety, or any nervous, or mental condition, fainting episode, blackouts, fit or paralysis of any kind?
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YES NO
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(b) High blood pressure, a heart condition, haemorrhoids, varicose veins, or other circulatory disorder, rheumatic fever, or diabetes?
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YES NO
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(c) a "slipped disc" or other spinal disorder, a hernia, or any rheumatic or arthritic condition?
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YES NO
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(d) Any respiratory, urinary, or allergic condition, or any disorder of the digestive system?
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YES NO
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(e) Any other condition or injury needing medical advice or treatment in the past five years, or any symptom or tendency that might necessitate this in the future?
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YES NO
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4. Have you ever been declined or accepted on special terms for life, accident or illness insurance?
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YES NO
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5. Have you ever received counselling or any medical advice, test or treatment in connection with A.I.D.S. or any A.I.D.S. related condition?
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YES NO
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6. Do the weekly benefits under all insurance carried by you, including those that are applied for in this proposal, exceed your average weekly net earnings?
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YES NO
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7. Do you anticipate that you might:
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(a) Travel extensively or reside temporarily outside the United Kingdom?
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YES NO
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(b) Undertake more than 20 air flights per annum, or fly other than as a fare-paying passenger? If so please state full details and expected number of flights.
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YES NO
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(c) Engage in football, rugby, equestrian or winter sports, or any other sports or pastimes rendering you liable to personal injury?
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YES NO
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10. Have you smoked within the last 24 months
YES NO
To the best of my knowledge and belief the information provided in connection with this proposal, whether in my own hand or not is true and I have not withheld any material facts. I understand that non-disclosure or misrepresentation of a material fact may entitle Underwriters to void the Insurance. (N.B. a material fact is one likely to influence acceptance or assessment of this proposal by Underwriters. If you are in any doubt as to whether a fact is material or not you must disclose it.)
I understand that Underwriters will determine their terms and conditions upon the information provided in connection with this proposal, and I further understand that the signing of this proposal does not bind me to complete or Underwriters to accept this Insurance.
The parties to this Insurance are free to choose the law applicable to this insurance contract. Unless specifically agreed to the contrary this Insurance shall be subject to English Law.
Benefits and premium rates will be quoted by your Insurance Broker and are subject to Underwriters terms and conditions.
If you would like a copy of this Proposal Form sent to you, Please advise your Insurance Broker.
A copy of the full Certificate of Insurance may be seen upon application to your Insurance Broker.
Any enquiry or complaint should be addressed in the first instance to the issuing Insurance Broker. If you are not satisfied with the way a compliant has been dealt with you may ask the Complaints and Advisory Dept at Lloyds to review your case without prejudice to your rights in law.
The address is: Complaints and Advisory Dept, Lloyd's, One Lime Street, London EC3M 7HA. Telephone: 020 7623 7100.
E-mail / fax / or post this form.
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Individual Personal Accident Insurance