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Single Policy
Joint Policy
Full Name:
DOB:
Smoker
Non-smoker
Male
Female
Partner name:
DOB:
Smoker
Non-smoker
Male
Female
Type of Cover:
Level Term Life Insurance
Level Term Critical Illness
Level Term Life & Critical Illness
Decreasing Life Insurance
Decreasing Critical Illness
Decreasing Life & Critical Illness
Amount of Cover:
£20,000
£25,000
£30,000
£35,000
£40,000
£45,000
£50,000
£55,000
£60,000
£65,000
£70,000
£75,000
£80,000
£85,000
£90,000
£95,000
£100,000
£105,000
£110,000
£115,000
£120,000
£125,000
£130,000
£135,000
£140,000
£145,000
£150,000
£155,000
£160,000
£165,000
£170,000
£175,000
£180,000
£185,000
£190,000
£195,000
£200,000
£205,000
£210,000
£215,000
£220,000
£225,000
£230,000
£235,000
£240,000
£245,000
£250,000
£255,000
£260,000
£265,000
£270,000
£275,000
£280,000
£285,000
£290,000
£295,000
£300,000
£325,000
£350,000
£375,000
£400,000
£425,000
£450,000
£475,000
£500,000
£550,000
£600,000
£650,000
£700,000
£750,000
£800,000
£850,000
£900,000
£950,000
£1,000,000
£1,100,000
£1,200,000
£1,300,000
£1,400,000
£1,500,000
£1,600,000
£1,700,000
£1,800,000
£1,900,000
£2,000,000
£2,100,000
£2,200,000
£2,300,000
£2,400,000
£2,500,000
£2,600,000
£2,700,000
£2,800,000
£2,900,000
£3,000,000
How Many Years?:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
Landline:
Mobile:
Email:
