Accident, Sickness & Unemployment

Home address
First name
Last name
Telephone No.
Employment Status
Date of Birth
Gross Monthly Income
Time with Employer
years   months  
Are you permanently resident and working within the UK, Channel Islands or Isle of Man and eligible to receive Jobseeker's Allowance? Do you sit on the board of directors or similar senior management committees in the business you work in?
Are you now and have you been for the past six months in continuous permanent employment, contract employment or self employment for more than 20 hours per week? Have there been any redundancies in the business you work in over the past 24 months?
Is your work temporary, casual or seasonal (including any work for a temporary, employment agency)? Do you hold any shares in the business you work in?
Have you at any time during the past 24 months been registered as unemployed? Are you currently receiving medical treatment or medical care of any kind, or awaiting referral for consultation treatment?
Have you been during the past 24 months, or are you in dispute or in the course of any disciplinary action with your employer? Have you had any illness or other treatment in the last three years including ever attending any hospital or clinic or had any specialist tests or investigations including those of a routine or minor nature?
Do you know of any redundancies, restructure, reorganisation, financial or contractual threats within the business you work in, even if you do not believe these actions will result in you becoming unemployed? Are you transferring cover from another provider?
(If yes, we will send you a Transfer Form)
Subject to underwriting, on what date would you like cover to start?    
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