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Insurance Quotation - Underwriting Application
If you have received an insurance quotation, and would like to apply for a confirmed price, please complete the form below with as much relevant information as available. There is no commitment to take out the policy, but the insurance premium will be confirmed based on your background, and medical history. Full policy details can then be sent via post, and/or email. Your rights under the Data Protection Act
 
We are able to provide insurance premiums which are discounted from the standard insurers prices, by refunding commision back to the client.
 

APPLICANT DETAILS

1st Applicant 2nd Applicant
Sex
Title
Forename(s)
Surname
Previous surname
Date of birth (dd/mm/yyyy)
Age
Current address
Postcode
Telephone numbers Home
Work
Mobile
Email address
Preferred mode of contact
Do you have any dependants?
- If 'Yes', how many?
Relationship to other applicant (If 'Other', please specify in Notes box.)
Are you in good health?
Have you smoked in the last 12 months? (If 'Yes', please specify in Notes box.)
Notes

OCCUPATION

1st Applicant 2nd Applicant
Occupation/Job title
Employment status (If 'Other', please specify in Notes box.)
Are you full time or part time (Part-time defined as under 16 hours per week)
On what basis?
Date commenced current employment (dd/mm/yyyy)
Notes

INCOME & OUTGOINGS

Income 1st Applicant 2nd Applicant Joint
If employed:
Basic salary p.a.
Guaranteed additional p.a. (overtime, bonus etc)
Regular additional p.a. (overtime, bonus etc)
If self-employed:
Number of years accounts available
Net profit last year
Previous year
Year before that
Details of any other income:
Pensions
Rental
Investment
State benefits
Allowances
Other (please specify in Notes box.)
Total annual income
Net monthly take home pay (A)
Do you see your income changing in the near future? (If 'Yes', please specify in Notes box.)
Notes
Outgoings 1st Applicant 2nd Applicant Joint
Would you like to look at your monthly outgoings in detail? If 'Yes', please complete the detailed breakdown of outgoings overleaf. If 'No', just complete the total boxes below.
Total monthly committed outgoings
Total monthly discretionary outgoings
Total monthly outgoings (B)
Do you see your outgoings changing in the near future? (If 'Yes', please specify in Notes box.)
DISPOSABLE MONTHLY INCOME (a-b)
Notes

Select the items you need




TERM & CRITICAL ILLNESS

If Term Assurance is required: 1st Applicant 2nd Applicant
What amount of cover do you require? (excluding existing arrangements)
Lump sum or Annual income
Cover basis
If cover basis is increasing, by how much? - If %age, please specify

Premium type
How many years do you want cover for?
Do you require any additional benefits?
- If 'Yes', which? Waiver of premium
Terminal illness 		Waiver of premium
Terminal illness
Is the cover to be a single or joint application?
If Critical Illness is required: 1st Applicant 2nd Applicant
What amount of cover do you require? (excluding existing arrangements)
Lump sum or Annual income
Cover basis
If cover basis is increasing, by how much? - If %age, please specify

Premium type
How many years do you want cover for?
Do you require any additional benefits?
- If 'Yes', which? Waiver of premium
Terminal illness 		Waiver of premium
Terminal illness
Is the cover to be a single or joint application?
Material facts: 1st Applicant 2nd Applicant
Are there any material facts that should be disclosed (medical conditions, claims history, etc). (If 'Yes', please specify in Notes box.)
Notes

PAYMENT PROTECTION INSURANCE (PPI) & INCOME PROTECTION

1st Applicant 2nd Applicant
Will you still receive a regular income?
How much would you receive?
What is the source of this income?
What is the amount of monthly mortgage payment to cover?
What is the amount of additional monthly amounts to cover?
If PPI is required: 1st Applicant 2nd Applicant
What type of benefit is required Accident
sickness & unemployment
Accident & sickness only
Unemployment only
Payment protection
Mortgage payment protection
 Accident
sickness & unemployment
Accident & sickness only
Unemployment only
Payment protection
Mortgage payment protection
What amount of cover do you require? (excluding existing arrangements)
What frequency of payment do you require?
What period could you wait until the benefit was payable? days days
Cover basis
If cover basis is increasing, by how much? (if %age, specify)

Premium type
Do you want waiver of premium?
Is the cover to be a single or joint application?
If income protection is required: 1st Applicant 2nd Applicant
What amount of cover do you require? (excluding existing arrangements)
What frequency of payment do you require?
What period could you wait until the benefit was payable? weeks weeks
Do you want waiver of premium?
Material facts: 1st Applicant 2nd Applicant
Are there any material facts that should be disclosed (medical conditions, claims history etc). (If 'Yes', please specify in Notes box.)
Notes

PRIVATE MEDICAL INSURANCE (PMI)

1st Applicant 2nd Applicant
What type of cover do you require?
Standard policy excess (If 'No', please specify in Notes box.)
Is the cover to be a single, joint or family application?
Preferred premium frequency
Do you want waiver of premium?
Material facts 1st Applicant 2nd Applicant
Are there any material facts that should be disclosed (medical conditions, claims history etc). If 'Yes', please specify in Notes box.)
Notes

BUILDINGS & CONTENTS

1st Applicant 2nd Applicant
Address of property
Postcode
Number of bedrooms
Type of property
Type of property
If Buildings cover is required: 1st Applicant 2nd Applicant
Year of construction
Is the property of non standard construction (i.e. thatched roof, barn conversion etc)? (If 'Yes', please specify in Notes box.)
Buildings sum insured
Accidental damage included?
Standard policy excess (If 'No', please specify in Notes box.)
Are all your doors and windows locked by a key? If 'No', give details in Notes box
Do you have a burglar alarm? If 'Yes', give details in Notes box.
Are you in a neighbourhood watch scheme? If 'Yes', give details in Notes box.
Has your property, or any property within 200 yards of your property, been affected by subsidence, heave or landslip? If 'Yes', give details in Notes box.
Do you have a functioning smoke alarm?
Has your property been affected by flooding? If 'Yes', give details in Notes box.
Notes
If Contents insurance is required: 1st Applicant 2nd Applicant
Contents sum insured
Standard policy excess
Accidental damage included?
Personal possessions away from home
Single item limit amount
Material facts: 1st Applicant 2nd Applicant
Are there any material facts that should be disclosed (medical conditions, claims history, etc). (If 'Yes', please specify in Notes box.)
Notes