Group Personal Accident Insurance

Insurance2day Insurance Services Ltd are authorised and regulated by the Financial Services Authority and are members of:

COMPANY DETAILS

Company Name:

Contact Name - Title & Surname:

Contact Name - First Name:

Business Address:

Postcode:

Contact Number:

E-mail Address:

Business Description:

Number of Years Trading:

Renewal Date:

Target Premium (£):

COVER REQUIRED

Insured Persons:

If Named, please give details:

Period of Cover:

Territorial Limits:

Clerical/Managerial Wage Roll (£):

No of Clerical/Managerial Employees:

Manual Wage Roll (£):

No of Manual Employees:

Details of Work Away From Premises:

Additional Information:

Details of Work Outside of U.K.:

ADDITIONAL INFORMATION

Please provide details of ALL and ANY losses you have suffered or claims you have made in the last five years (please advise date(s), cost(s) and circumstances:

Any additional information/comments or material facts that may affect an insurers willingness to offer cover:

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