LIFE ASSURANCE QUOTATION REQUEST
FIRST LIFE
1. Title (FIRST LIFE) ----------------------------------
MR
MRS
MISS
MS
DR
OTHER
2. Surname (FIRST LIFE) -----------------------------
3. First Names (FIRST LIFE)--------------------------
4. Date of Birth(FIRST LIFE)--------------------------
e.g.. 26/02/1990
5. Marital Status (FIRST LIFE)-----------------------
Partnered
Married
Married - common law
Single
Separated
Widowed
6. Is the first life insured a smoker?------------------
NO
YES
SECOND LIFE
7. Title (SECOND LIFE)
---------
-----------------------
MR
MS
MRS
MISS
DR
OTHER
8. Surname (SECOND LIFE)
---------
------------------
9. First Names (SECOND LIFE)
---------
--------------
10. Date of Birth(SECOND LIFE) ---------------------
e.g.. 26/02/1990
11. Marital Status (SECOND LIFE) -------------------
Partnered
Married
Married - common law
Single
Separated
Widowed
12. Is the second life insured a smoker?-------------
NO
YES
THE INSURANCE
13. Is the FIRST INSURED a home owner?----------
YES
NO
14. The purpose of the cover is for
PERSONAL LIFE ASSURANCE
MORTGAGE PROTECTION FOR AN INTEREST ONLY MORTGAGE
MORTGAGE PROTECTION FOR A REPAYMENT MORTGAGE
MORTGAGE PROTECTION FOR AN ENDOWMENT MORTGAGE
OTHER - PHONE ME AND I'LL EXPLAIN
15. Please
DO NOT INCLUDE
INCLUDE
critical illness cover.
16. Policy with a term of
years.
17. Amount of cover required - £
18. Alternatively the maximum monthly payment required should not
exceed £
CONTACT DETAILS
19. House number or name-----------------
20. Street -------------------------------------
21. Town/City --------------------------------
22. County ------------------------------------
23. Postcode ---------------------------------
-
24. Home telephone -------------------------
25. Work telephone -------------------------
26. Mobile ------------------------------------
27. E-mail Address:*
REQUIRED
(
T
he email address is required as the server autoresponds with important telephone numbers where you are able to follow up on the quotation if necessary)
.
