Personal Accident & Illness Quote Request

Please complete the questions below and click submit for your personal accident & illness insurance quote

1Policy Information > 2Medical History & Additional Information Required > 3Questions
Are you an existing Jim's Franchisee or becoming a new Jim's Franchise?

Are you an existing Jim's Franchisee or becoming a new Jim's Franchise? Yes - STOP!! please go to our home page a click on Jim's Franchisee Quotes No
Name Name First Last
Occupation
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone
Email
Policy Information
What date do your require your policy to start from? What date do your require your policy to start from? / DD / MM YYYY
Name of the person to be insured Name of the person to be insured First Last
Date of Birth Date of Birth / DD / MM YYYY
Height (cms)
Weight (kgs)
Please select the type of cover you require:
Please select the level of cover you require:
Capital Benefit - Accident only - Death benefit:
If you require a level of cover greater than the amount allowable, please specify the weekly amount you would like covered;