Get a Quote

Personal Accident Insurance

  

Name & Surname*

ID card number*

Date of birth*

Address*


Phone number*

Mobile number*

Email Address*

Main Occupation*

Secondary Occupation*

Your hobbies, habits & pastimes*

What kind of insurance do you require?

Do you require cover on*

- Occupational basis
- 24 hour basis

Do you wish cover to operate*

- Maltese Islands
- Worldwide

Do you wish to cover any other persons apart from yourself?

Name & Surname

Date of Birth

Relationship

Occupation

Name & Surname

Date of Birth

Relationship

Occupation

Name & Surname

Date of Birth

Relationship

Occupation

Name & Surname

Date of Birth

Relationship

Occupation

Benefits to be insured

Benefit

Sum required (in euro)

Death / Full Payment disablement*

Temporary total disablement

Medical expenses

Have you or any other person proposing to be insured

Been involved in any accidents during the past five years?*

Ever had a proposal for insurance declined, renewal refused, cover terminated, increased premium required or special conditions imposed by any insurer?

Ever been convicted of (or charged but not yet tried with) arson, or any offence involving dishonesty of any kind?

I have read and accept the Terms and Conditions