Personal Accident and/or Illness Enquiry Form

You must give full and true answers to all questions. If you do not do so, your insurance cover may not protect you in the event of a claim. You should keep a record of all information supplied. Print options are available upon completion of this form.

Name(s)*:
(State names of all partners and trading name if not a limited company)
Address Line 1*:
Address Line 2:
Address Line 3:
Postcode*:
Telephone Number*:
Fax Number:
Email Address*:
Web Address:

Current/Previous Insurer or Broker Name:
Renewal Date:
Renewal/Target Premium:
How did you hear about Lycetts?*


How many years experience do you have in this industry?
Please state fully all activities in which you or your firm are involved:

1. Name:
Date of Birth:
Occupation:
Sickness:	YesNo
Benefit Required:
2. Name:
Date of Birth:
Occupation:
Sickness:	YesNo
Benefit Required:
3. Name:
Date of Birth:
Occupation:
Sickness:	YesNo
Benefit Required:
4. Name:
Date of Birth:
Occupation:
Sickness:	YesNo
Benefit Required:
Please provide details of any illnesses, operations or bodily injuries (except childhood complaints) suffered by anyone to be covered