Personal Accident Insurance
CHUBB
Policyholder Information
Policyholder Name
*
State
*
Select...
New South Wales
Victoria
Queensland
South Australia
Western Australia
Tasmania
Northern Territory
Australian Capital Territory
Postcode
*
Business Description
*
Broker Name
*
Insurance Period From
*
Insurance Period To
*
Coverage Details
Select all coverage types that apply
*
Working hours including commuting
Working hours excluding commuting
24 hours coverage
Journey to and from work only
Other coverage
Persons Covered
Who should be covered by this policy?
Employees
Other
Number of persons to be covered by state
NSW
ACT
QLD
VIC
TAS
SA
NT
WA
Benefits & Excess
Accidental Death Benefit
Benefit Amount ($)
*
Multiple
Weekly Injury Benefit
Weekly Amount ($)
*
Percentage of Salary (%)
Weekly Sickness Benefit
Weekly Amount ($)
*
Percentage of Salary (%)
Excess
Nil excess
Other excess period
Additional Benefits
Other Benefits
Include other benefit period
Fractured Bones Benefit
Include Fractured Bones Benefit
Dental Benefit
Include Dental Benefit
Aggregate Limit
Aggregate Limit Amount ($)
Declaration
Are you subject to an enterprise bargaining agreement?
Name of Signatory
*
Position of Signatory
*
Date
*
Authorised Signature
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