1. Do you want joint cover for you and your spouse/Partner*?

   No

   Yes

2. Mr Mrs Ms Miss

3. Name: *

4. Date of Birth: *

5. Telephone: *

6. Email: *

7. Address: *

8. Post Code: *

9. Occupation: *

10. Your gross annual income (£): *

11. current sick pay benefit (if any):

12. Are you self employed?

    Yes

    No

13. Are you a director?

    Yes

    No

14. Do you have a mortgage?

    Yes

    No

15. Are you a smoker?

    Yes

    No

16. Do you have dependent children?

    Yes

    No

17. Please choose at least 2 of the following:

18. Life insurance

    Yes

    No

19. Critical Illness

    Yes

    No

20. Income protection

    Yes

    No

21. Unemployment cover

    Yes

    No

22. Additional Comments:

*This information is required for an enquiry