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Term Insurance Quotation Form

Policy Details  
Benefit Type:
Term (in Years):
Insurance Amount Required:
or
Your chosen premium:

:
Inflation Proofing?: Yes No Info
Waiver of Premium: Yes No Info
Purpose for insurance :
   
Personal Details:  
  First Life Second Life
Title:
First Name:
Surname:
Date of Birth:
Smoker: Yes No Yes No
Occupation:
   
Address Line 1
Address Line 2
Address Line 3
Address Line 4
Postcode:
   
*Daytime Telephone:
Alternative Contact Number :
*Email:
   
Comments:
   
 

 

Waiver of Premium
This option ensures that if you cannot work for a prolonged period (usually six months plus) you will not be required to pay your premiums after this date, until you should return to work.
You will be required to pay an additional premium for this option, and additional underwriting may be required which can prolong the application process.
If required, we will quote for this option with a six month deferral period.  If you require a shorter term, please specify.

Inflation Proof
This option will automatically increase the sum assured on your policy each year by an amount which broadly reflects the rate of inflation.
Your premium will also increase annually to pay for this feature.

Post 
All of the relevant documentation will be posted to your home address, with a prepaid envelope in which you may return any documentation.