ASR Underwriting Agencies

Quick Quote - Personal Accident Insurance

For an indicative quote, please complete and submit the form below.

For a more accurate quotation, please download, complete and return the Proposal Form.

Broker Details

Your Name

Broker Name

Your Email

Your Phone

Your Fax

Insured's Details

Full Name of Insured

Address of Insured

Occupation

Details of Occupations Duties

Details of Hobbies
eg skydiving, abseiling, jetskiing etc

Date of Birth

Height

Weight

Tick which type of Cover is required

Personal Accident ONLY
Personal Accident & Illness

Weekly Accident Benefit

Weekly Ilness Benefit

Capital Benefits

Is there any Pre-existing Conditions?

yes no

Details of Pre-existing Conditions

Details of any other History
we should know about

Is quote required for 24 hr cover?

yes no

Is quote required for outside working hours only?

yes no

Comments

PLEASE NOTE
This is for the use of NON BINDING INDICATIVE QUOTATION PURPOSES ONLY and is subject to a satisfactorily completed Proposal Form Prior to Binding

Please enter code

Need Help?
Please contact our office.

Mon - Fri : 8:30am - 5pm

P | 07 3442 3333

F | 07 3807 6839

enquiries@asruw.com.au

Quick Quote - Personal Accident Insurance

Broker Details

Insured's Details

Need Help? Please contact our office.

Need Help?
Please contact our office.