Request a Quote
If you are an employee of any of the companies listed to the right, please click on your company logo and log into the secure site, whereby you will see specific information relating to your company scheme.
You can Estimate a Premium and Request a quote from within this secure site, thus ensuring that you have full details of the unique cover available to you. Please do contact us if you require your username and password. |
| 1. First Name * |
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| 2. Last Name * |
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| 3. Date of Birth (DD/MM/YYYY) * |
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| 4. Employer * |
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| 5. Occupation * |
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| 6. Rank * |
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| 7. Home Address * |
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| 8. Postcode * |
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| 9. Phone Number (Mobile) * |
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| 10. Fax No. |
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| 11. Email * |
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| 12. Correspondence Address (if different) |
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Income Protection Insurance
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| Maximum monthly Voluntary Benefit available is £5,000 subject to a maximum of 85% of your Net Monthly Income |
| 13. Monthly benefit required * |
£
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Personal Accident Insurance
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| Maximum sum insured is £250,000. Cover is only available up to age 64. |
| 14. Sum to be Insured * |
£
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| Personal Statement |
| 15. What is your height * |
(m) |
| 16. Your weight * |
(kg) |
| 17. Do you hold any similar cover with any other insurance company for the Section(s) you have selected? * |
Yes
No |
| 18. If you answered yes to the question above please enter the insurance company, the type of policy (e.g Life), the benefit, commencement date and any endorsements / policy exclusions for each policy you hold |
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| 19. Has any other Insurer declined, deferred, accepted on special terms, excluded or withdrawn a Policy of insurance on your life? * |
Yes
No |
| 20. Have you ever had or been treated or been told that you have venereal disease, AIDS, AIDS-related complex or AIDS-related conditions? * |
Yes
No |
| 21. Have you ever had or been suspected of having, or been diagnosed with, heart trouble, high blood pressure, chest pain, kidney or bladder disease, diabetes, cancer, tumours, ulcers, asthma, mental or nervous disorders or epilepsy? * |
Yes
No |
| 22. Have you ever had, or been suspected of having, or been diagnosed with arthritis, rheumatism, paralysis, loss of use of limb, muscle, joint or back problems, hearing or eye sight problems? * |
Yes
No |
| 23. Have you ever taken steroids, anti-hypertensive drugs or any other drugs not normally available through your doctor or pharmacist? * |
Yes
No |
| 24. Do you have any other illness or medical impairment? * |
Yes
No |
| 25. Has your Pilot/Flight Engineer license ever been suspended or cancelled on medical grounds? * |
Yes
No |
| 26. What is the name and address of your doctor? * |
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| 27. Have you consulted or been referred to a Medical Specialist (other than for routine aviation medical) in the last 3 years? * |
Yes
No |
| 28. Are you a smoker? * |
Yes
No |
| 29. If you answered "Yes" to any other question(s) please provide full details in the section labelled "Other Details" including dates, doctors attended, time off work, treatment, etc. below. Continue on a separate sheet if necessary. |
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| Declaration |
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I, the proposed Applicant for Catlin Insurance Company (UK) Limited described above do hereby declare that all statements made in the Personal Statement concerning myself are complete and true and that they are correctly and fully recorded and that no material information has been withheld or omitted concerning my past and present state of health and habits of life.
I agree that any Medical Practitioner who has been, or may hereafter be consulted by me, is authorised and directed by me to divulge to the Insurer any information he/she may have with regard to myself. Furthermore, I hereby consent that the medical information declared above and by any Medical Practitioner can be used for underwriting purposes by insurers and their agents.
I also give permission that all data provided may be held, processed and shared in order to arrange insurance and/or premium finance (if applicable).
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| 30. I have read and agreed the Declaration above (TICK BOX) * |
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