Personal Accident Proposal Form Step 1 of 3 33% Personal DetailsName* Date of Birth* DD slash MM slash YYYY Place of Birth* Height* Weight* Postal Address*Telephone*Email* Occupation StatusEmployedSelf EmployedHousehold DutiesUnemployedStudentClerical DutiesSupervisorMachinery OperatorManual WorkerOtherOther Employer’s full name* Period of insuranceFrom:* DD slash MM slash YYYY To:* DD slash MM slash YYYY Details on Person Have you had any serious injuries or illness during the past 5 years? Do you suffer from any physical defect or infirmity? Do you suffer from any heart disorder, aids, fits, diabetes, mental disorder, limited vision, or hearing or any other chronic disease? Are you being exposed to any particular hazard in relation to your nature of duties or lifestyle? Are you engaged in any sport activities? Has any injured in respect of Life, Accident or Medical Insurance ever declined your proposal on impose special conditions? If any of the above was yes please give details Have you ever claimed or received compensation under any accident or sickness policy? If yes please state name of insured, amounts and dates Do you intend to leave Cyprus? If yes, what part of the world do you intend to visit, for what period and for what purpose?Kindly state Make and Type of body of the car which you usually travel. Scale Of Compensation requiredOption 1: DEATH Sum Insured Option 2: PERMANENT TOTAL DISABLEMENT, LOSS OF LIMBS OR SIGHT OR HEARING Sum Insured Option 3: TEMPORARY TOTAL DISABLEMENT Per Week Option 4: MEDICAL EXPENSES For Each Accident For Data Protection Company Policy Click Here. * I have read the Data Protection Company Policy posted on this website I herewith provide Royal Insurance Company Ltd (and any successors and assignees thereof), my express and unconditional consent regarding the processing and creation of data records in electronic and physical form, of all my relevant personal data, that may include sensitive data which I have declared and submitted