iProtect Ph Life and Non Life Insurance Services

Non-Life Insurance Inquiry - Personal Accident

Full Name *

Phone *

Street Address

City

Country

Postal code

Occupation

Annual Income (Estimate) *

Date of birth *

Age, Height (cm), Weight (kg) *

Beneficary/ies: Name and Relationship *

Please answer the following:

1. With what company and for what amounts are you presently assured against accidents?

2. Has any Insurer in respect of life or accident insurance ever declined or imposed special terms to insure you, or cancelled or refused to renew your policy? If answer is "Yes", please give full details:

3. Have you any physical defect or infirmity or any kind or have you ever had diabetes, tuberculosis, varicose veins, disease of the heart or brain, amputation, impairment of hearing or of sight of either eye or any nervous affection? If answer is "Yes", please give full details:

4. Do you engage in any of the following excluded risk? Please underline activity if your answer is "Yes". Rugby Football, Motorcycling, Scootering, Hunting, Polo Playing, Mountaineering, Yachting, Scuba Diving, use of Woodworking Machinery and Metal Working Machinery?

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