Please take reasonable care to answer all the questions honestly and to the best of your knowledge. If you don't answer the questions correctly, your policy may be cancelled, or your claim rejected or not fully paid.
Cover type
Date from which cover is to start
Day Month Year
Proposers Personal Information
Title
Forename(s)
Surname
   
Day Month Year
  Date of Birth
What is your email address
By supplying data you are agreeing to our Terms of Business and our Privacy Security Policy
Telephone number
Risk Address Postcode
  
  Address
   
   
   
Employment type
1) Are you now and have you been for the past 6 months in continuous employment?
2) Do you know of any impending unemployment which may affect you?
3) Have you been resident in the UK, channel islands or Isle Man for the past 6 months?
Partners Personal Information
Partner's Date of Birth
Day Month Year
Employment type
1) Are you now and have you been for the past 6 months in continuous employment?
2) Do you know of any impending unemployment which may affect you?
3) Have you been resident in the UK, channel islands or Isle Man for the past 6 months?
Client Salary Information
Proposer's Annual Salary
Partner's Annual Salary
Your safeguard calculator (Amount of monthly outgoings)
Mortgage / Rent
HP / Loans / Credit Cards
Gas / Electricity / Water
Insurances / Council Tax
Education Fees
Other Expenses
Monthly benefit required:
Your cover options - for help and more information click here
1) How many days would you like before your policy starts to pay for accident and sickness cover
When you have an accident or become sick you maybe entitled to sick pay from your employer for a certain amount of days, this can reduce your premium amount so check your contract. If you have no entitlement for sick pay then choose back to day one.
2) How many days would you like before your policy starts to pay when you are unemployed
 


If you have any problems please call 01608 647601 with your reference 2027123324644
You can also recall your quote at a later date if you keep note of your email and reference
Terms of business
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