Life Insurance

Cover Required

Single Joint

Is this policy to cover just yourself, or yourself and your partner?

Amount of Cover (£)

This is the amount of money which will be paid out in the event of a claim during the term of the policy. If you have chosen decreasing cover this will reduce over the term in line with a repayment mortgage.

Term (years)

This is the number of years the cover will last for. This must be greater than 5 years, and no more than 100.

Type of policy

Level Decreasing

Level means the cover will remain constant throughout the term of the plan. Decreasing means the cover will reduce in line with a repayment mortgage during the term of the plan. Read more about the types of life insurance policy that are available.

Critical Illness Cover

Yes No

Critical Illness is an optional extra under all Term Assurance Plans which allows for the lump sum to be paid not only on death, but also in the event of diagnosis of certain critical illnesses, such as Heart Attack, Stroke, Major Organ Transplant, Blindness, Total & Permanent Disability etc. Read more about critical illness.

Title

Select Mr Mrs Miss Ms Other

Initials

Surname

Contact Phone

Email

House Name / No

Postcode

Gender

Male Female

Date of Birth

Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / Year 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929

Have you smoked in the last 12 months?

Yes No

Have you smoked any tobacco products within the last 12 months, or used any products containing nicotine?

Please tick the following box to confirm that you have read and understood our Initial Disclosure Document before proceeding (opens in new window).