Personal Accident Insurance
Tel: 01992 707318
   
To obtain a quote, please complete the following, and press the "Submit Request" button at the bottom of the form. We will contact you by telephone or email with a quote.
email Address  
Confirm email Address  
Title
First Name
Surname
House Number/Name
Street
Town
County
Post Code
Country
Tel. Number - Day
Tel. Number - Evening
Date of Birth
DD/MM/YY
Occupation
Where Did You See Us Advertised
Existing Customer (Any Product) YES NO 
Commencement Date
   
Are You a Pleasure Rider Only

YES NO 
   
Do You Work with Horses (Inc. Full Time/Part Time/Voluntary) YES NO 
If you answered YES, give examples. e.g. groom, instructor, etc
Are You a Professional Rider/Competitor YES NO 

Do you take part in any of the following high risk activities:
Polo
Steeplechasing
Flat Racing
Hurdle Racing
Harness Racing
Point-to-point Racing
Arab Racing
Eventing (All levels)
Team Chasing

 YES NO 

Please state which Equestrian activities you take part in. e.g hacking, hunting, showjumping, etc.
Any other form of racing or equestrian group activity. e.g. Horseball.
Please list which ones, or state NONE.
Level of Cover: 

Standard

Standard + Adult Super Cover (Loss of earnings)
Declaration: I declare that the information I have given above is true and complete. I have not withheld any material facts (see IMPORTANT NOTES.) I agree that this proposal shall form the basis of the Contract between me and Shearwater Insurance.