Group PA application form and supplementary questionnaire

    Personal Accident

    1. If insurance is required for multiples or proportions of Annual Salary, please note Annual Salary is considered to be the total annual remuneration, excluding payments or overtime, commission or bonus.

    Category

    Categories, or names and occupations of persons to be insured

    Estimated number of persons

    Estimated total annual earnings

    A

    B

    C

    D

    State amounts to be insured under each heading

    Category

    Lump sum benefit - state multiple of annual salary required

    Income benefit* Temporary disablement per week

    A

    B

    C

    D

    * Normally the weekly earnings - expressed as 1/52nd of Annual Salary.

    Temporary Partial Disablement is normally 40% of Temporary Total Disablement.

    If insurance is required for fixed sum benefits

    Category

    Categories, or names and occupations of persons to be insured

    Estimated number of persons

    A

    B

    C

    D

    State amounts to be insured under each heading

    Category

    Lump sum benefit

    Income benefit* Temporary disablement per week

    A

    B

    C

    D

    If Permanent Disablement is to be included, Please tick which option is required.

    Standard ScaleExtended Scale

    If you wish to include Medical Expenses necessarily incurred as a result of accidental Bodly injury, please tick the sum insured required.

    If flying is undertaken, state maximum total lump sum benefit for all persons flying together in any

    If other flights are undertaken, state

    Operative Time - tick as required

    Category

    Any Time

    Occupational Accidents Only*

    Occupational Accidents Plus Commuting*

    External Business Journeys Only**

    A

    B

    C

    D

    * If less than 5 persons are to be covered
    Any Time' is the only option available.

    ** If this option is required, please complete the 'Business Travel Abroad' section also

    Do you wish to include the illness benefits extension?

    YesNo

    Do you wish to reduce the premium by foregoing payment of the income benefit for the initial period of disablement?

    YesNo

    If yes, for how long?

    N.B A minimum period of 7 days is applicable under the Illness Benefit Extension

    Do you wish to have the income benefit payable for a period other than 104 weeks?

    YesNo

    If yes, state period required:

    Give particulars below of all accidents (and illnesses if the Illness Benefit Extension is to be included(which have occurred during the last five years within the Operative Times ticked above

    Date

    Circumstances

    Nature of Injury/Illness

    Period of Disablement

    Business Travel Abroad

    1. Do you require cover to respect of internal journeys involving flying or overnight accommodation?

    YesNo

    2. Do you require cover for accompanying spouses, and children under 18 years, travelling abroad with your knowledge and agreement?

    YesNo

    3. If the answer to question 2 is 'Yes' give details of persons to be insured and travel undertaken during last twelve months (including employees spouses and children)

    Travel undertaken in last 12 Months - USA/Canada

    Duration (In days)

    Categories of persons to be insured

    Occupations

    Description of persons

    No. of persons

    No. of journeys

    Average

    Maximum

    A

    B

    C

    D

    Travel undertaken in last 12 Months - Elsewhere in the world

    Duration (In days)

    Categories of persons to be insured

    Occupations

    Description of persons

    No. of persons

    No. of journeys

    Average

    Maximum

    A

    B

    C

    D

    Travel undertaken in last 12 Months - internal

    Duration (In days)

    Categories of persons to be insured

    Occupations

    Description of persons

    No. of persons

    No. of journeys

    Average

    Maximum

    A

    B

    C

    D

    4(a). Have the number, destination and duration of journeys altered significantly during the last 3 years, or is any significant change expected during the last 3 years?

    YesNo

    4(b).Will any journey involve manual work

    YesNo

    4(c).Will any journey to be areas where disturbances are in progress or reported as being imminent?

    YesNo

    If yes, In either case, Please give full details

    5. Please specify the Sums Insured required

    Medical & Emergency Travel Expenses

    Cancellation, Curtailment and Change of Itinerary

    Category (as above)

    Personal Baggage

    Personal Money/Credit Cards

    Travel Delay - No of Units

    A

    B

    C

    D

    6. Give details below of all accidents, illnesses and losses during the last five years which would have given rise to a claim under the proposed Travel Insurance

    Declaration

    I/We declare that to the best of my/our knowledge and belief, the above statements made by me/us
    or on my/our behalf are true and complete and I/we agree that this proposal
    shall be incorporated in the contract between me/us and the Company.
    I/We agree to accept a policy in the Company's usual form for this class of insurance.

    Name