Personal Accident Insurance
Tel: 01992 767666
   
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 
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

  
YES NO 
Any other form of racing or equestrian group activity. e.g Horseball?
Please list which Ones
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.
Shearwater Insurance Services Ltd
Registered Office: 2 Bath Place, London, EC2A 3JJ. Registered in the UK Company No: 02701633