Hello In order to process / confirm the insurance quotes to you, I just need to know a few details including your Doctors / GP’s details and of course if there are any medical conditions to factor in.

Insurance Information

Insurance Information

For existing Clients we will match you against current client file
Just as a data security check - to make sure we update 'your' / the correct persons case file


other please note at end
Please note any health issues in notes below
If you want to tell us anything about the products selected just note it here, eg want joint life policy at £34.53 as per quote


1 Home emergency cover = Provides upto £300 for emergency tradesmen, burst pipes, locksmiths,
2 Family Legal Protection = Provides upto £50,000 legal expenses cover for property disputes, employment contract disputes, civil claims


eg none, or 6 months full pay- / 6 months 50%
eg ,none, or 6 months full pay- / 6 months 50%

Decreasing Insurance means it decreases in line with your mortgage and should always - be just enough to cover the mortgage balance. But You can OPT to add an extra amount to cover Funeral and related expenses, Typically we would recommend people add an extra £10,000 to their policies to cover all the funeral costs.

ADDITIONAL OPTION - Income Protection / Family Income benefit

For policies like above where you receive a monthly payout, eg Income Protection of £1,000 pcm, you can opt to have the payout level indexed to Inflation / RPI. - Why would you do this well £1,000 pcm may well buy you a lot less in 15 or 20 years time - than you could buy today. ( note if you opt for this the annual premium although guaranteed not to increase - will go up by RPI to maintain the payout level at the increasing amount )

FINAL OPTION - available on ALL Policies

You can have WAIVER OF PREMIUM added to any policy for typically just an extra +£2.40 pcm . WOP pays out if you are off ill from work and cant afford the monthly premium payments, - then WOP takes over and makes those payments for you. As the average claim on Income protection is 5 years 7 months then if your policy was £32pcm then it would have covered £2,144 of monthly premium payments. All for just a small extra amount each month.


eg 123 High Street
eg 5 ft 4 or 176 cm
eg 10 stone 6lbs or 102 kgs
eg men 32" trouser size / Women dress size 14
eg 36" trouser or dress size 16

1 glass of wine (175ml) = 2 units,
1 pint standard beer/lager = 2 units,
1 measure of spirits = 1 unit

Normally expected to see 14 units or less per week

eg 12 units
eg 10 stone 6lbs or 102 kgs
Please note any health issues in notes below
Please note any health issues in notes below
That involved specialist or hospital treatment
Please note any health issues in notes below
Please note any health issues in notes below
Eg asthma = Inhaler type and prescription, etc Note if you prefer to keep medical info Private / confidential, just tell us here, so we can inform insurers and their medical team will contact you instead. We will base quote on our knowledge and the premium will be adjusted by the insurer once they have discussed your health issues.
Please tell us their name so we can thank them