Personal Accident Form You must give full and true answers to all questions. If you do not do so, your insurance cover may not protect you in the event of a claim. You should keep a record of all information supplied. Step 1 of 2 50% Name*(State names of all partners and trading name if not a limited company)Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*FaxEmail* WebsiteCurrent/previous insurer or broker nameRenewal date DD MM YYYY Renewal/target premiumWhen do you require cover to commence? DD MM YYYY How did you hear about Lycetts?E.g. recommended, internet search, yellow pages?How many years experience do you have in this industry?How long has your business been established for?Please state fully all activities in which you or your firm are involvedDo you hold Certificates of Competence in the use of chainsaws or spraying?YesNoPlease detail which certificates are held and when they were obtained.Are you a member of any Professional Association?YesNoIf yes please advise name of association and membership number.Please provide details of any other person or organisation that you are employed by (not as a sub-contractor). Personal accident and sicknessDo you require this cover?YesNoBenefit required£10,000/£100 p/w£15,000/£150 p/w£20,000/£200 p/w£25,000/£250 p/w£30,000/£300 p/w£35,000/£350 p/w1. Add an individual Add 1. Name First Last 1. Date of birth DD MM YYYY 1. Occupation1. SicknessYesNo2. Add an individual Add 2. Name First Last 2. Date of birth DD MM YYYY 2. Occupation2. SicknessYesNo3. Add an individual Add 3. Name First Last 3. Date of birth DD MM YYYY 3. Occupation3. SicknessYesNo4. Add an individual Add 4. Name First Last 4. Date of birth DD MM YYYY 4. Occupation4. SicknessYesNoPlease provide details of any illnesses, operations or bodily injuries (except childhood complaints) suffered by anyone to be covered.