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Personal Accident Insurance Proposal Form

  • Date Format: MM slash DD slash YYYY
  • Benefits

  • required (see below)

  • Period of Insurance

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY


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.


ADeathThe full sum insured
BPermanent Total DisablementA sliding scale up to 100% of the sum insured as follows
Loss of both hands, both feet or any two thereof100%
Loss of sight in both eyes100%
Loss of one hand or foot and sight of one eye100%
Total paralysis100%
Loss of one arm or one hand60%
Loss of one leg or one foot50%
Loss of sight in one eye50%
Loss of thumb25%
Loss of index finger15%
Loss of any other finger6%
Loss of big toe5%
Loss of any other toe3%
Loss of hearing in both ears50%
Loss of hearing in one ear15%
CTemporary Total Disablement1% of the sum insured not exceeding 100% of weekly salary.
DTemporary Partial Disablement0.50% of the sum insured no exceeding 100% of weekly salary.
EMedical ExpensesPercentage of the sum insured chosen.