Personal Accident Insurance Quote

Please complete and submit the required information in the form below to receive your Personal Accident Insurance quotation

* Required Information.

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Personal Information

Proposer name: *

E-mail: *

Date of Birth

Please Select the Day, Month & Year you were born

Day: *

Month: *

Year: *

Occupation: *

Daytime telephone number: *

Correspondance address: *

Address to be insured (if different):

What Directed You To Our Website?:

Additional Details

Details of any criminal convictions:

Details of any insurance refused/declined/terms imposed:

Height: *

Weight: *

Details of any pre-existing medical conditions:

Details of any participation in any sporting activities or pastimes:

Details of any previous claims:

Weekly or monthly income (after tax and NI): *

Cover Options

Death and capital benefits (£):

Weekly personal accident benefit (£):

Weekly sickness benefit (£):

Benefit period, 12 months/24 months:

12 Months

24 Months

Terms & Conditions

I understand Ryan Insurance Group use a select panel of insurers for this type of business
My quotation will be valid until the end of the current month
I will take reasonable care to answer all the questions honestly and to the best of my knowledge, as failure to do so may mean the cancellation of my policy and or my claim being rejected
Ryan Insurance Group is obliged by law to give me the opportunity to hear how they give advice, deal with compensation and handle complaints. This information is contained within their terms of business agreement (attached).

Agreement

I have read and agree to the terms and conditions above: *

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