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Name
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Date of Birth
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Age
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Your main E-mail Address
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Do you have an alternative E-Mail Address
(in case your primary email address ever lapses)
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Telephone
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Mobile
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Fax
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Address
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Town/City
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Post/Zip Code
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Country Of Residence (where you live)
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Nationality (where you were born)
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Occupation
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Employed/Self Employed
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Employed
Self Employed
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Please give a detailed description
of your work duties
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Marital Status
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*Have you ever smoked in the last 12 months? |
Yes
No
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Please provide details of any health
issues we should know about
If you have no health issues to
detail, please enter 'none'
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Policy Details
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Please state the country you require cover for
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Please quote your gross annual income
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Amount of monthly benefit required in £'s sterling?
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Quick Calculator
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What deferment period would you prefer before payout?
Self-employed only
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Do you receive Statutory Sick Pay from your employer?
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Yes
No
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How many months at Full Pay? |
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How many months at Half Pay? |
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To what age do you wish the plan to pay if incapacitated
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Selecting 'upto age 65' increases
the premium considerably
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Do you wish benefits to be indexed linked?
(normally 5%)
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Yes
No
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Do you have a monthly or annual budget?
If Yes, please specify
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Yes
No
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* Please confirm that you have
seen our Key Facts document
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Key Facts seen
- PDF file: 
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How did you find us
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Have you bought any insurance from CRITICAL ILLNESS INSURANCE UK Before?
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(Hold down "Ctrl" to make multiple selections)
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How did you find out about our site?
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If Search Engine, Which one did you use?
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FINALLY, PLEASE CHECK THAT YOU HAVE COMPLETED ALL BOXES ABOVE
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