01993 777850 contactus@saua.co.uk

Specialists in…
Personal Accident, Travel and Liability cover.

Personal Accident Quote Submission Form

UNDERWRITING INFORMATION

A. Death, eyes, limbs, hearing in both ears, speech PTD: 
B. Temporary Total Disablement (weekly) - (Benefit Period 104 weeks):

 £ 
 £ 

C.
Loss of Hearing in one ear: 25% of PTD Benefit
Paraplegia: £50,000
Quadriplegia: £100,000
Domestic Service Expenses: £10,000
Home Adaption Expenses: £25,000
Retraining Expenses: £15,000
Urgent Expenses following Accidental Death: £1,000

LIFESTYLE INFORMATION  If you answer Yes please give: full details:
Does the Insured take part (or practice) in any of the following:

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