Name                             

Company                     

Address                        

Post Code                          

Trade or Occupation 

Date of Birth                 

Capital Benefit required            £25,000 £50,000           Accidents only    Accidents and illness
(lump sum payable in the event of 
accidental death, loss of limbs etc.) 

 Weekly Benefit required       £250 per week £500 per week      Accidents only    Accidents and illness   
(payable while you are totally unable
 to work following an accident) 

 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       Illness  26 weeks 52 weeks Not applicable
(the length of time during which 
weekly payment will be made

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.

Tell us how to get in touch with you:

Please contact me as soon as possible regarding this matter.

 

Your initial quote, plus a policy summary will be sent to you by email or fax

The information you have provided  will only be used to allow us to prepare your quotation.  

We do not share our information with any organisation outside our own group other than for the purposes of placing and servicing your insurance. 

Click here to view our privacy statement

 

Please check this box if you do not wish us to notify you of other products 

which we believe may be of interest.

Copyright © 2005 [Harvington Underwriting Ltd]. All rights reserved.
Revised: December 20, 2006 .