Lloyd's Accident or Accident and Illness Proposal Form

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Today's Date *

YYYY

Name of the proposer (if other than the person to be insured) *

Name of applicant

Full address of the proposer *

Street address, City, State & Zip Code (e.g. 9420 SW 77th Ave. #200 Miami, FL 33156)

Relationship to the person to be insured *

e.g. Employer

Nature of business or occupation in which you are engaged (if more than one, state all). If your duties are not solely of an office or administrative nature please give details. *

State period of insurance and commencement date required. *

If unknown, enter "tba"

What capital sum do you wish to insure? *

Which of the following scale of benefits do you require? (see table below) *

A, B, C, D, E, F or G

Compensation payable in respect of ACCIDENT

The policy includes medical expenses up to 15% of the total amount of any claim paid for temporary total or temporary partial disablement, without additional premium.

Illness outside Europe is excluded. Therefore, if you have selected a scale of benefits which includes illness, please provide location(s) and duration(s) *

If you travel by air as a passenger in a properly licensed multi-engined aircraft being operated by a licensed commercial air carrier or owned and operated by a commercial concern, please state the approximate number of flights and anticipated destinations. *

If this questions does not apply to you, enter "n/a".

Please advise of any pre-existing conditions of any person to be insured *

Do you require medical and repatriation endorsement? *

Print name of the proposer *

Copy of crew manifest needed

Please email us (info@darlowinsurance.com) separately a copy of the crew manifest as it is required.

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