Your Details

1. Title Dr Mr Mrs Miss Ms *
2. Forename *
3. Surname *
4. Are you a DDA Member? Yes No *
5. Position *

Practice Address

1. Practice Name *
2. Number *
3. Street Name *
4. Town *
5. County
6. Postcode *

Contact Details

1. Telephone *
2. Email Address *
3. What prompted you to visit our website DDA Mailshot DDA Conference DDA HQ Google Internet Management in Practice Magazine Management in Practice Event Practice Business Magazine PR Word of Mouth *

The Basis of your Quotation

To calculate your Indicative Locum Insurance quotation please use the drop down menus to select the basis of cover for each individual as required, leaving all additional lines blank. If you require cover for more than 14 individuals please call us.

For more information on each of the cover areas please click on the i for a brief explanation.

 

Staff Member	Weekly Benefit The weekly benefit to be paid in the event of a claim	Deferred Period The initial period of absence after which the weekly benefit would become payable	Accidental Death (optional) This is optional and provides a lump sum benefit in the event of Accidental Death or Accidental Permanent Total Incapacity
1	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
2	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
3	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
4	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
5	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
6	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
7	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
8	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
9	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
10	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
11	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
12	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
13	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000
14	£200 £300 £400 £500 £600 £700 £800 £900 £1000 £1100 £1200 £1300 £1400 £1500 £1600 £1700 £1800 £1900 £2000 £2100 £2200 £2300 £2400 £2500	2 Weeks 4 Weeks 8 Weeks 13 Weeks	N/A £40,000 £50,000 £60,000 £70,000 £80,000 £90,000 £100,000 £150,000

1. Are all staff listed above under the age of 65?
   This policy is not available for customers over the age of 65 – in some instances we may be able to refer individual cases to the underwriters depending on the circumstances.
   Yes No *

Final Details

If you have an existing policy please provide:

1. Renewal Date
2. Current Premium
3. Existing Provider

1. We may wish to contact you by post, telephone, or email regarding relevant products or services. If you do not wish to be contacted in this way, please tick this box  

2. I have read and agree with the Privacy Policy    

3.