Personal Accident Proposal Form

    MarriedSingleDivorced/Separated

    DeathPermanent DisablementTemporary DisablementMedical Expenses

    YesNo

    Heart disordersNervous disordersVaricose veinsParalysisInfection of the eyesInfection of the ears

    YesNo

    NOTE: If you wish to be covered whilst engaged in any such activities special application must be made

    YesNo

    declinedcancelledhad special terms imposed?