Confidential life insurance Form

Including Life Cover, Critical Illness Cover & Income Protection

Tick Checkbox for Joint Policy

personal DETAILS

1st applicant Title Mr Mrs Miss Ms Dr First Name Surname Marital Status Please select Married Single Divorced Widowed Separated Cohabiting Date of Birth (dd/mm/yyyy) Smoker? yes no On Electoral Roll? yes no Are you a UK Resident yes no Number of Dependants

2nd applicant Title Mr Mrs Miss Ms Dr First Name Surname Marital Status Please select Married Single Divorced Widowed Separated Cohabiting Date of Birth (dd/mm/yyyy) Smoker? yes no On Electoral Roll? yes no Relationship to first applicant Please Select Husband Wife Partner Other If other, please specify

Contact details
Best phone contact number
Best time to call	9 - 12 a.m.	12 - 5 p.m.	5 - 9 p.m
E-mail address
Address
Postcode
Previous address if less than 3 years at the above
Address
Postcode

your employment details

1st applicant Self Employed? yes no National Insurance Number Employer's Name How long have you worked there? Employer's Address Your Occupation Type of Employment Please Select Full Time Part Time Agency Temp

2nd applicant Self Employed? yes no National Insurance Number Employer's Name How long have you worked there? Employer's Address Your Occupation Type of Employment Please Select Full Time Part Time Agency Temp

your income
If self employed, can you supply a letter from your accountant confirming income? Please Select Yes No				How many years?
If yes,	Accountant's Name
	Accountant's Address
	Accountant's Tel. No.
Your gross annual income with overtime & bonus (if self employed net pre tax profit)			£
Your partner's gross income with overtime & bonus			£

Type of Cover
Do you know the type of cover you require? yes	no
I would like an advisor to call me to discuss the types of cover available for my / our individual needs (Please indicate the best time to call in the contact details section above) Life or Critical Illness Cover Amount of cover required (£) (£20,000 - £1,500,000) Period of cover Please Select 1 - 5 years 5- 10 years 10 - 15 years 15 - 20 years 20+ years Type of cover Please Select Life insurance Critical illness Life & critical illness Mortgage protection Family income benefit Accident, sickness and unemployment Business life cover Group life cover Key man insurance Other Not sure Do you or your partner have any existing life or critical illness cover? > yes          > no If YES, please give details below.   Owner Provider (including Employer Provisions) Start Date End Date Sum Assured (£) Monthly Premium (£) Self Partner Self Partner Self Partner     When do you want the cover to start?     Income Protection In the event of being unable to work due to ill health or incapacity, how much would you currently need to maintain your standard of living? If you are unable to quantify the amount, please use the comments box below to clarify your situation. Benefit required £ per month Deferred Period (weeks) Please Select 4 8 13 26 52 (Deferred period normally covers length of time sick pay is received from employer.) Do you or your partner know of any impending redundancy? > yes > no Do you or your partner have any cover in the event of being unable to work yes no If YES, please give details below. Owner Provider (including Employer Provisions) Start Date End Date Monthly Benefit (£) Monthly Premium (£) Deferred Period (weeks) Self Partner Self Partner Self Partner   Do you or your partner have any other types of cover, e.g. Private Medical Insurance yes no If YES, please give details below.     Owner Provider (including Employer Provisions) Start Date End Date Monthly Benefit (£) Monthly Premium (£) Deferred Period (weeks) Self Partner Self Partner Self Partner   When do you want the cover to start?

comments / additional information

Please tick this box if you are a Broker / Solicitor / Introducer
Full Name * Tel. No. E-mail