Quote Request for AFA Personal Accident & Sickness Insurance, for Self Employed, or employed by a Non-Payroll Deduction Company

Note, this form is only applicable if you do not have the option for payroll deductions via your employer, or if you are self-employed. If you are employed by one of the transport companies listed here, you can apply directly by completing an Application Form, otherwise if you are employed in any other industry, please Contact Us for more information. Likewise, if you require a quote for Public Liability, please contact us to discuss your options.

*
*
*
*
*
*
*
*

Please be as detailed as possible

*