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;