Personal Accident Quotation - Middlesea Insurance Malta

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	Personal Accident
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	Professional Indemnity Insurance

To obtain a quote, please provide the following details:

IMPORTANT NOTE:
Insurers, their agents and Insurance associations share information with each other to prevent fraudulent claims and for underwriting purposes. In the event of a claim, some or all of the information you supply in this form and in the claim form together with other information relating to the claim may be provided to other Insurers, their Agents and Insurance Associations. All questions must be answered in full. Ticks and dashes are not sufficient.

Your Details

Title (Mr/Ms/Dr)
First Name		Last Name
I.D. Card number		Business or occupation:
Address		Telephone
Fax		Email address

Insurance Required

From:	dd/mm/yyyy

To:	dd/mm/yyyy

Information to be Provided by Proposer

1. Has any person to be insured sustained any accidents during
the past five years?

Yes No

If Yes, have these been claimed under a policy of insurance?

Yes No

2. Are you to the best of your knowledge and belief in sound physical and mental health and free from any physical defect or infirmity?

Yes No

If NO, please give particulars:

3. Do you require cover on Occupational Accidents only or on a 24 hour basis?

Occupational Accidents 24 hour basis

4. Are you currently or have you ever been insured for these risks?

Yes No If YES, please give particulars:

5. Would you like cover to be extended outside the Maltese Islands?

Yes No If YES, please state reasons:

6. Weekly Gross salary

€

7. Do you have other current policies with Middlesea Insurance

Yes No If Yes please specify:

Declaration

I/We hereby declare that the above information and statements are, to the best of my/our knowledge and belief, correct and complete. !/We agree that this proposal shall be the basis of the contract between me/us and MIDDLESEA INSURANCE P.L.C. and I/We agree to accept the Company’s standard form of Policy for the class of Insurance.

If the answers to all or any of the above questions have been written by others at my/our dictation or instruction I/We have read those answers and confirm that they are correct.

Important Note: Any other facts known to you, which are likely to affect acceptance or assessment of the risks proposed for insurance must be disclosed. Should you have nay doubt about what you should disclose, do not hesitate to inform us or your insurance adviser. This is for your own protection, as failure to disclose may mean that your policy will not provide you with the cover you require, or may perhaps invalidate the policy altogether.

Disclaimer
The Insurance will not be in force until the proposal has been accepted by the Company and the premium paid.

I/we acknowledge that Middlesea Insurance p.l.c. (MSI) may process the personal data that I/we provide in accordance with the Data Protection Act (Cap 440) and with the Data Protection Policy of the Company.

I/we acknowledge that I/we have a right to request to and rectification of such data as processed by MSI. Any such request must further be signed by myself as the applicant/joint assured/joint holder to whom the personal data relates.

We would like to keep you updated with our latest products & services. Your details will not be passed on to any third parties.

If you do not want to receive this information please tick this box

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	Middlesea Insurance p.l.c. Middle Sea House Floriana, FRN1442 Malta

	Tel: (+356) 21246262 Fax: (+356) 21248195

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Middlesea Insurance p.l.c. is a company authorised under the Insurance Business Act, 1998 to carry on both Long Term and General Business and is regulated by the Malta Financial Services Authority.Registration Number: C5553.

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