Locum Insurance Quotation Request Form

To request a quotation for Locum Insurance, please complete the short form below and click the Submit button to send to our offices to receive a no-obligation quotation.

Risk Details

Tell us about the staff you would like to include under this scheme

Staff Member 1

Staff Member 2

Staff Member 3

Staff Member 4

Staff Member 5

Staff Member 6

Staff Member 7

Staff Member 8

Staff Member 9

Staff Member 10

Staff Member 11

Staff Member 12

Staff Member 13

Staff Member 14

Staff Member 15

Staff Member 16

Staff Member 17

Staff Member 18

Staff Member 19

Staff Member 20

Staff Member 21

Staff Member 22

Staff Member 23

Staff Member 24

Staff Member 25

* This is the amount you want the policy to pay each week in the event of a valid claim. The amount you include here must be appropriate to the anticipated cost of that staff member's absence.

Pre-existing Medical Conditions

Non-Fortuitous Claims

Claims History

Declaration

I/we declare that the information disclosed on this proposal, is to the best of my/our knowledge and belief both accurate and complete.
I/we have taken care not to make any misrepresentation in the disclosure of this information and understand that all information provided is relevant to the acceptance and assessment of this insurance, the terms on which it is accepted and the premium charged.
I/we hereby consent to any information you may have about me being processed by you for the purposes of providing insurance and claims handling, which may necessitate your providing such information to third parties.

Click Here to Acknowledge Your Acceptance