Name of Company     

Address of Company  

Post Code                            

Trade or Occupation       
(please describe any hazardous work)          

Estimated Manual Wages in next 12 months          

Estimated Clerical Wages in next 12 months    

Has your business been involved in any incidents in the last 5 years which did or could have given rise to a claim of a type which this insurance is intended to cover?    Yes No

Cover Required

Death and Capital Benefits      2 x Annual Salary 3 x Annual Salary 4 x Annual Salary 5 x Annual Salary   Accidents only  
(lump sum payable in the event of 
death, loss of limbs etc.) 

Weekly Benefit required  50%  net weekly salary 75%  net weekly salary 100% net weekly salary   Accidents only   Accidents and illness   
(payable while totally unable
 to work)

Waiting Period                      7 days 14 days 3 weeks 4 weeks 9 weeks (a longer waiting period usually means a cheaper premium)
(the time you must wait 
before weekly benefits start) 

Payment Period                Accidents   52 weeks 26 weeks 104 weeks       Illness  26 weeks 52 weeks 104 weeks Not Applicable
(the length of time during which 
weekly payment will be made

Effective Time of cover         24 hours a day Working Time plus Commuting

Date from which you need cover to start (dd/mm/yyyy)   

Please enter below any further information that you think we should know  before preparing your quotation.

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Please contact me as soon as possible regarding this matter.

Your initial quote will be sent to you by email or fax

 

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Copyright ©  [Harvington Services Ltd]. All rights reserved.
Revised: December 20, 2006 .