Your details
Email
addresses
Phone
numbers
Full
name
Occupation
Nationality
Date of birth
Country
Non Smoker Smoker Do you smoke
Quote
details
Minimum
term
until
you
are
50
years
of
age.
What weekly
GBP income
do you want
to
be
insured
for (Maximum 75% of
current annual salary)
Weekly
amount
required
Your annual gross earnings
and
currency
Specify Annually Monthly
Will
you pay monthly or annually
Monthly payments
must be made
in
UK sterling by Visa, MasterCard or UK direct debit. Annual
payments
must be paid by
bank
transfer
or
cheque.
Must select 3 months 6 months
Your
benefit to start after
which
deferred period
Health requirements
Must Select Yes No
Can your doctor complete an English language questionnaire
Must Select Yes No
Can you have a
minor medical examination and blood test for
HIV and Hepatitis B
Regulations
To comply with offshore regulations can you provide photocopies of your passport and a utility bill or bank/Visa statement showing your name and residential address. The copies must be confirmed
as true copies of originals by one of the following a solicitor, lawyer, notary or your embassy or consulate.
Must Select Yes No
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