Impaired Life and Critical Illness Cover Quotations

This form is for people trying to obtain life or critical illness cover who have pre-existing medical conditions and / or dangerous occupations / hobbies. If you are a healthy life and are likely to be accepted on standard terms, please go to our on-line life cover quote system which will give you an immediate monthly cost comparison.

It is important to answer all questions fully so that an accurate assessment can be made by underwriters. Your data is provided in the strictest confidence and its use is fully covered under the Data Protection Act 1998. This form consists of two steps and the length will vary accoding to which pre-existing medical conditions have been diagnosed since we will require details on each disclosure.

Section 1: Policy & Personal Details

Protection type:      
Single / Joint Life:      
Product type:  
 
       
       
 
Amount of cover£
If applicable, amount of critical illness cover£
Term
For joint cover, would you like to apply for two single policies (recommended) rather than one joint policy?
 Your detailsYour partner's details
Title
If 'other' please specify
Gender
Surname
Forename(s)
Date of birth   (dd/mm/yyyy)   (dd/mm/yyyy)
Nationality
Marital Status
Relationship to the insured
Present occupation
Does your job involve working overseas?
If yes, then where?
Are you currently or have you ever been a resident or national of a country OTHER than the UK?
If yes, then where and when?
If no longer working, previous occupation
Date ceased   (dd/mm/yyyy)   (dd/mm/yyyy)
Postcode
Daytime telephone number
Evening telephone number
E-mail address
Sport / leisure activities
 
 
 
 
 
 
 
 
Please specify how often you undertake these activities and provide any information which you feel will clarify the nature of the risks taken: