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Would you like to include cover for critical illness on the policy?

Yes No This cover pays out a cash lump sum if you are diagnosed with one of the critical illnesses specified in the policy

How much cover would you like? (minimum £10,000) Things to think about: your mortgage balance, your other total financial commitments,
maintaining your family's lifestyle, and any dependents' current or future educational needs

How long would you like the policy to cover you for? Note: Consider when your mortgage will be paid off and when your dependents will be self-sufficient. Life insurance policies don't cover you indefinately

About You

Title

First Name:

Surname:

Date of birth (dd/mm/yyyy):

Contact Phone Number:

Email:

Have you smoked or used nicotine products in the last 12 months?

Yes No

About Applicant 2

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