Personal Accident Insurance Proposal Form - Himalayan Everest Insurance

Proposers name in full*
Address*
Street Address City State / Province / Region
Occupation (describe fully)*
Are you primarily engaged in administrative, secretarial or managerial functions?*
Do you engage in manual labour?*
Do you use power driven machinery?*
Date of Birth*
Date Format: MM slash DD slash YYYY
Height*
Weight*
Do you suffer from any disability or infirmity? If so give details*
Do you play or engage in any type of sport, trekking, rock climbing or any other hazardous pursuit?*
Are you now insured or proposing to insure against Personal Accident with another insurer?*
Has any company ever declined, cancelled, refused to renew, increased the premium or imposed special conditions for Personal Accident Insurance?*
Have you ever made a claim under a Personal Accident Policy? If yes give full details.*
Benefits
required (see below)
Capital Sum Insured*
What benefits do you require (Tick as appropriate)*
- A only
- A & B only
- A, B, C & D
Medical Benefits (E)
Name of beneficiary in the event of death*
Period of Insurance
From*
Date Format: MM slash DD slash YYYY
To*
Date Format: MM slash DD slash YYYY
*
I hereby declare that the above statements are true and that I have withheld no information which might influence the acceptance of this proposal. I agree that this proposal shall be the basis of the contract between me and the Company and deemed to be incorporated in the Policy.

PERSONAL ACCIDENT INSURANCE

Subject to the more precise terms of the Policy Personal Accident insurance provides a fixed amount, based on the sum insured, in the event of death or disablement following an accident. You choose the benefits to suit your particular requirements.

Rates vary upon your occupation and whether or not you wish to include risks such as motorcycling, riot and strike, and other more hazardous perils. A quotation will be supplied upon receipt of a completed proposal.

BENEFITS AVAILABLE

	BASIC BENEFIT	AMOUNT PAID
A	Death	The full sum insured
B	Permanent Total Disablement	A sliding scale up to 100% of the sum insured as follows
	Loss of both hands, both feet or any two thereof	100%
	Loss of sight in both eyes	100%
	Loss of one hand or foot and sight of one eye	100%
	Total paralysis	100%
	Loss of one arm or one hand	60%
	Loss of one leg or one foot	50%
	Loss of sight in one eye	50%
	Loss of thumb	25%
	Loss of index finger	15%
	Loss of any other finger	6%
	Loss of big toe	5%
	Loss of any other toe	3%
	Loss of hearing in both ears	50%
	Loss of hearing in one ear	15%
C	Temporary Total Disablement	1% of the sum insured not exceeding 100% of weekly salary.
D	Temporary Partial Disablement	0.50% of the sum insured no exceeding 100% of weekly salary.
E	Medical Expenses	Percentage of the sum insured chosen.

Benefits

required (see below)

Period of Insurance

PERSONAL ACCIDENT INSURANCE

BENEFITS AVAILABLE