Life Insurance / Critical Illness Quotation

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

Income Protection
Title
First Name:
Surname:
House Number or Name:
Street:
Town or City:
Postcode:
Daytime Telephone: *
Evening Telephone: *
Email: *
Are you? male female
For which would you like a quotation?
a) Only Life Insurance?

b) Only Critical Illness?

c) Life combined with critical illness? 		yes

yes

yes
Have you smoked any tobacco products in the last 12 months? yes no
Your Date of Birth?
How long do you want to be covered for?
(Minimum of 5 years, max up to your 70th birthday.)		  years
How much cover do you require?
How would you like to pay your premium? Monthly Annually
Is it to cover your mortgage? yes no
If so, is it repayment? yes no
If it is repayment, do you need cover that reduces as the debt reduces? yes no
Would you like the waiver of premium option added to your quote?
(This means your premiums will be paid if you are unable to work due to accident, sickness or disability.)		 yes no
What is your occupation?:
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.