Personal Accident for Sports and Leisure Activities

If you are off work temporarily who pays the bills? In the event of an injury which prevents you from working, who pays the mortgage and provides financial assistance to look after your family? Will statutory sick pay cover your normal outgoings?

A Personal Accident policy is a sensible method of continued income and at the same time provides you with peace of mind.

WHEN DOES COVER APPLY?

You can take advantage of a 24 hour cover that applies all day, every day, covering accidents whether you are working at the time or not. On the other hand you can restrict cover to accidents occurring only during the leisure activity. Please note that if you are employed full time in a leisure activity 24hour cover is automatic.

Note: Complete the following details and we will provide a quote within 24 hours


	About You

Personal Details

Title *

Forename *

Surname *

Date of Birth *
(dd/mm/yyyy)

Height *

Weight *

Occupation (Main) *

Occupation (Part/Temp)

Telephone Number *

Email Address

Address Details

House Number/Name *

Address Line 1 *

Town/City *

County

Post Code *


	Your Cover

Benefit Option Required

Policy Start Date *
(dd/mm/yyyy)

Please list all leisure activities for which cover is required *

If you wish to be covered for Skydiving, you will need to call our office on:
0870 121 7590


	Other Information

Have you suffered from any illness, disability or condition which has affected your ability or could in the future affect your ability, to undertake the activities now being proposed for insurance. If YES please provide details.	Yes No

Have you ever been declined, deferred or accepted on special terms for Life Assurance or Personal Accident Insurance or has any company cancelled or declined to renew your policy or requested to amend benefits, terms or conditions. If YES please provide details.	Yes No

Are you now insured under a separate Personal Accident Policy? If YES please state the name of the insurer and the level of benefits.	Yes No

Does your average NET weekly income exceed the amount of weekly benefits payable under this and any other policy you hold? If YES please provide details.	Yes No

Will you pursue your leisure activity or occupation outside the United Kingdom? If YES please provide details.	Yes No


	Declaration

I declare that the above information is, to the best of my knowledge and belief, correct in every aspect and no material facts have been withheld. I consent to the company seeking medical information from any Doctor, who at any time, has attended me concerning anything which affects my physical or mental health or seeking information from any insurance office to which a proposal has been made for insurance on my life and I authorise the giving of such information. I agree that this proposal shall on acceptance of the quotation and payment of the premium form part of the contract and I agree to accept a policy in the Company's usual form for this class of business. I declare that the amount of benefit for which I propose is reasonable with regard to my circumstances and any weekly benefit for which I propose, together with all sources of income payable during disablement, does not exceed 75% of my normal weekly income.

I have read and accept the above declaration

* Indicates required field

Harrison Beaumont Insurance Services Limited is authorised and regulated by the
Financial Services Authority registration number 303968 www.fsa.gov.uk/register/

Harrison Beaumont Insurance Services Limited
2 Des Roches Square • Witney • Oxfordshire • OX28 4LG
Tel: 0870 1217 590 • Fax: 0870 1217 592 • info@hbinsurance.co.uk