Group Personal Accident and TravelProposal

Please provide all relevant information and email your response to:

CaSE Insurance

Tel: 0333 800 9838

Fax: 0333 800 9848

Group Personal Accident Cover

Occupational Titles / Categories of staff or Named persons

Please list below for each category

1.Occupational titles, or categories of staff, or named persons to be insured (e.g. Directors, Trustees, Mr Peter Smith, all other employees, volunteers, etc.)

2.Whether full or part-time

3.Description of Occupation (e.g. Clerical & Administrative, Carers, Manual Labour, etc)

4.If cover is to be on a 24 hour basis or Occupational Risks only (for volunteers the Policy will be limited to Occupational Risks only)

5.Sums insured: Please state if cover is required for a multiple of salary / percentage of weekly wage or for fixed sums insured (as volunteers are not salaried, a fixed sum basis will be used)

1. / 2. / 3. / # / £ / 4. / 5.
Occupational Titles / Categories / Full-Time or Part-Time / Description of Occupation / Total Number within Category / Total Annual Wageroll for Category / Basis of Cover Required / Required Sum Insured (see below)
24-Hour Basis
 / Occupation Only
 / % of Total Annual Salary / Weekly Wage
 / Fixed Sums Insured

(a)
(b)
(c)
(d)
(e)
(f)
(g)

CaSE Insurance is a trading name of CaSE Insurance Services Limited. Appointed representative of aQmen Limited.
Authorised and regulated by the Financial Conduct Authority. To check these details on the Financial Services Register:
Registered in England: Number 07456845. Registered Address: Manor House, 1 The Crescent, Leatherhead, Surrey, KT22 8DY

GPA&T/PF: KB23.001Page 1 of 6

Group Personal Accident Cover

Sums Insured

Item 1 - Death

Item 2 - Loss of one limb

Item 3 - Loss of sight of one eye

Item 4 - Loss of two limbs

Item 5 - Loss of sight of both eyes

Item 6 - Loss of one limb and Loss of sight of one eye

Item 7 - Permanent Total Disablement

Item 8 - Temporary Total Disablement

Item 9 - Temporary Partial Disablement

% of Total Annual Salary / Weekly Wage / Fixed Sums Insured
Category / Items 1 – 7 (% of Annual Salary) / Item 8 (% of Weekly Wage) / Item 9 (% of Weekly Wage) / Items 1 – 7 (Amount) / Item 8 (Amount) / Item 9 (Amount)
(a) / £ / £ / £ / £ / £ / £
(b) / £ / £ / £ / £ / £ / £
(c) / £ / £ / £ / £ / £ / £
(d) / £ / £ / £ / £ / £ / £
(e) / £ / £ / £ / £ / £ / £
(f) / £ / £ / £ / £ / £ / £
(g) / £ / £ / £ / £ / £ / £

Please provide details of any individuals who fall outside the Policy Age Limits (Minimum 14 years of age, maximum 85 years of age):

Group Personal Accident and TravelProposal

Group Travel Cover

Travel Pattern

Please confirm that: / Confirm  / And/or please provide comments
  1. The Insured does not own, lease or operate an aircraft

  1. There is no offshore exposure

  1. There is no use of helicopters or non-standard aircraft

  1. There are no known scheduled aircraft accumulations (or state numbers of travellers likely to travel within the same aircraft)

  1. There are no known non-scheduled aircraft accumulations (or state numbers of travellers likely to travel within the same aircraft)

Please detail below each category of traveller

1.Full-time and Part-time Salaried Directors and Employees

2.Trustees

3.Volunteers

4.Others for whom you are seeking to provide Travel Cover (individual Names and roles)

Category: / 1. / 2. / 3. / 3.
Description / Full-time and Part-time Salaried Directors and Employees / Trustees / Volunteers / Others (individual Names and role)
# / £ / Numbers:Wageroll: £ / Numbers: / Numbers: / Name(s):

Please provide details of any individuals who fall outside the Policy Age Limits (Maximum 85 years of age):

Travellers - Category 1

Country / Up to 6 days / 7 to 21 days / Over 21 days
Number of trips / Average duration (days) / Number of trips / Average duration (days) / Number of trips / Average duration (days) / Overseas Postings / Numbers / Duration (days)
UK – trips involving overnight accommodation and/or air travel
Europe
Worldwide excluding USA/Canada*
Worldwide including USA/Canada*
* Countries to which the FCO advises no travel or none but essential Travel
Afghanistan
Chechnya
Iraq
North Korea
Somalia
Others – please list:

Travellers - Category 2

Country / Up to 6 days / 7 to 21 days / Over 21 days
Number of trips / Average duration (days) / Number of trips / Average duration (days) / Number of trips / Average duration (days) / Overseas Postings / Numbers / Duration (days)
UK – trips involving overnight accommodation and/or air travel
Europe
Worldwide excluding USA/Canada*
Worldwide including USA/Canada*
* Countries to which the FCO advises no travel or none but essential Travel
Afghanistan
Chechnya
Iraq
North Korea
Somalia
Others – please list:

Travellers - Category 3

Country / Up to 6 days / 7 to 21 days / Over 21 days
Number of trips / Average duration (days) / Number of trips / Average duration (days) / Number of trips / Average duration (days) / Overseas Postings / Numbers / Duration (days)
UK – trips involving overnight accommodation and/or air travel
Europe
Worldwide excluding USA/Canada*
Worldwide including USA/Canada*
* Countries to which the FCO advises no travel or none but essential Travel
Afghanistan
Chechnya
Iraq
North Korea
Somalia
Others – please list:

Travellers - Category 4

Country / Up to 6 days / 7 to 21 days / Over 21 days
Number of trips / Average duration (days) / Number of trips / Average duration (days) / Number of trips / Average duration (days) / Overseas Postings / Numbers / Duration (days)
UK – trips involving overnight accommodation and/or air travel
Europe
Worldwide excluding USA/Canada*
Worldwide including USA/Canada*
* Countries to which the FCO advises no travel or none but essential Travel
Afghanistan
Chechnya
Iraq
North Korea
Somalia
Others – please list:

Claims Experience – Last 5 Years

Group Travel
Group Personal Accident

CaSE Insurance Services Limited

Manor House, 19 Church Street

Leatherhead, Surrey KT22 8DN

T: 0333 800 9838

F: 0333 800 9848

CaSE Insurance, coverholder at Lloyd’s

GPA&T/PF: KB23.001Page 1 of 6