Accident Sickness & Unemployment Quotation Request

1. First Applicant's Details
Name * Title First Last Suffix
Date of Birth * / DD / MM YYYY
Employment Status *
Occupation
Current Employer's Name
Nature of Business
Length of Service
Are you a smoker? *
2. Second Applicant's Details
Name Title First Last Suffix
Date of Birth * / DD / MM YYYY
Employment Status *
Occupation
Current Employer's Name
Nature of Business
Length of Service
Are you a smoker?
3. Contact Details
Address
Street Address

Address Line 2

Town / City

County

Post Code

Country
Daytime Telephone Number

Please enter numbers only with no spaces
Mobile Telephone Number

Please enter numbers only with no spaces
Email Address
4. Cover details
Type of Cover Required *
First Applicant Net Monthly Income £ . Pounds Pence
First Applicant Monthly Cover Required £ . Pounds Pence
Second Applicant Net Monthly Income £ . Pounds Pence
Second Applicant Monthly Cover Required £ . Pounds Pence
Policy Excess in Days *
Policy Commencement Date / DD / MM YYYY
Type of Scheme Months Free *
Mortgage Details
Mortgage Start Date / DD / MM YYYY
Mortgage Lender
Mortgage Loan Amount £ . Pounds Pence
Monthly Mortgage Repayment £ . Pounds Pence
Other Mortgage Related Payments £ . Pounds Pence
5. Underwriting Questions Please read the following statements carefully and tick only those which apply.
Applicant 1.
The applicant is working for less than 16 hours per week (all work must be within the UK, Channel Islands or Isle of Man) Yes No
The applicant's work is temporary, casual or seasonal or includes any work for a temporary employment agency. Yes No
The applicant has been registered as unemployed within the last 12 months. Yes No
The applicant is aware of circumstances which may result in them becoming unemployed. Yes No
The applicant is in dispute or in the course of any disciplinary action with their employer (including any performance related issues). Yes No
The applicant has consulted a doctor (or consultant) in the last 12 months. Yes No
Applicant 2.
The applicant is working for less than 16 hours per week (all work must be within the UK, Channel Islands or Isle of Man) Yes No
The applicant's work is temporary, casual or seasonal or includes any work for a temporary employment agency. Yes No
The applicant has been registered as unemployed within the last 12 months. Yes No
The applicant is aware of circumstances which may result in them becoming unemployed. Yes No
The applicant is in dispute or in the course of any disciplinary action with their employer (including any performance related issues). Yes No
The applicant has consulted a doctor (or consultant) in the last 12 months. Yes No

Accident Sickness & Unemployment Quotation Request

Accident Sickness & Unemployment Quotation Request

1. First Applicant's Details

2. Second Applicant's Details

3. Contact Details

4. Cover details

Mortgage Details

5. Underwriting Questions Please read the following statements carefully and tick only those which apply.

Applicant 1.

Applicant 2.