Insurance - Personal Accident
Personal Accident and Emergency Repatriation (PA) insurance is available for Iraq where most standard covers exclude it. Through links with other specialist brokers a specific cover for work in Iraq has been developed. This policy provides the broadest possible cover with high quality medicare procedures tailored to each policyholder, all for very competitive premiums.

Comprehensive cover is available for virtually all territiories, please enquire.

This insurance includes the usually expected clauses such as; Death by accident, Loss of Sight in one or both eyes, Loss of Limbs, Disablement and Medical Expenses following an accident or illness Including Repatriation and 3 months follow home cover.

To enquire about Personal Accident Insurance, please complete and submit the form below:

PERSONAL ACCIDENT INSURANCE

 

This form, once completed, will be sent direct to our Insurance brokers who will act on this on your behalf. Gulf Capital will not retain the information contained in your completed form. Please note that where the brokers maintain risk and claim data/information/documents the brokers may hold data/information/documents electronically.

 

 

 

 

 

 

SECTION 1

 

 

 

    First Name

 

 

    Family Name

 

 

    Date of Birth

i.e. 07/11/1969

 

 

    Address Line 1

 

 

    Address Line 2

 

 

    Address Line 3

 

 

    City / Town

 

 

    Post / Zip Code

 

 

    Country

 

 

     

 

 

 

    Email address:

 

 

    Fax:

 

 

    Telephone:

 

 

    Mobile:

 

 

    Preferred Contact Method

 

 

 

 

 

 

    Employer/Business name

 

 

    Nature of business

 

 

    Occupation

 

 

 

 

 

 

SECTION 2

 

 

 

    Required Start date

 

 

    Required End date

 

 

    Country visited

 

 

 

 

 

 

SECTION 3

 

 

 
    Please contact me regarding other classes of insurance, please specify:

 

 

 

 

 

 

QUERIES:

 

 

 
    Please set out your question/s for the Broker in the box below and then submit. Ensure that you have completed Section 1. before submitting

 

 

 

 

 

 

 





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