Permanent Health Insurance & Income Protection

To receive a written quotation within 10 working days, please submit your details:

Life Insurance / Critical Illness Quotation
Title
First Name:
Surname:
House Number or Name:
Street:
Town or City:
Postcode:
Daytime Telephone: *
Evening Telephone: *
Email: *
Are you? male female
Have you smoked any tobacco products in the last 12 months? yes no
Your Date of Birth?
What is your gross salary per annum?
What is your occupation?
Please complete the questions for either
(A) Permanent Health Insurance or (B) Income Protection - whichever suits your needs best.
(A) Permanent Health Insurance
What deferment period do you require?
(This is the period from when the policy will start paying out.)		 after 4 weeks after 8 weeks after 13 weeks after 26 weeks after 52 weeks
If you cannot work due to accident, sickness or disability, for how long would you want to receive regular monthly payments? (minimum 5 years, max up to your 65th birthday). years
 
(B) Income Protection
What deferment period do you require?
(This is the period from when the policy will start paying out.)		 after 2 weeks after 4 weeks
If you cannot work due to accident, sickness or disability, for how long would you want to receive regular monthly payments? (normally pays for up to one or two years). years
Comments
How did you hear about us?
* I understand that this application will be passed to a life insurance specialist1 who will contact you with your quotation. yes
  1. As we are health insurance specialists, we currently advise on private medical insurance policies at present. However, we will refer your enquiry on to a skilled adviser who specializes in this field. You will receive the same high standard of service through them as you would through datahealth, as they are also authorized and regulated by the Financial Services Authority.