1. Quick Quote

Mandatory fields are marked by *

1. Where do you permanently reside and work?
   ---Please select--- UK Channel Islands Isle of Man Non-UK resident *

2. Are you in continuous permanent employment, contract employment or self-employment and working for more than 16 hours per week?

   Yes   No *  

3. Are you aware that there may be redundancies, restructures, reorganisations, financial or contractual threats within the business you work?

   Yes   No *  
4. Type of product?
   ---Please select--- Accident and Sickness Accident, Sickness & Unemployment Accident, Sickness and Life Accident, Sickness, Unemployment and Life *
5. Amount of monthly benefit you require? £ ? The amount of monthly benefit must not exceed £2500 per month or 60% of your gross monthly income which ever is less.
   *
6. How many months of benefit? ? You can choose to receive benefit payments for up to 6 or 12 months if the product you select includes Unemployment cover.
   
   If there is no Unemployment cover included, you can choose you can choose to receive benefit payments for 6, 12, 18 or 24 months. Selecting a shorter benefit period can reduce your monthly premium.
   ---Please select--- 6 months 12 months 18 months 24 months *
7. Amount of time before benefits will
   be paid? ? This is known as the 'wait period'. It is the length of time you have to wait from your claim date until you will receive benefit payments under the policy. Selecting a longer 'wait period' can reduce your monthly premium. If you need help deciding which wait period is most suitable for you, please call 0800 038 1183 where our team will be happy to help.
   ---Please select--- 14 days - back to day 1 30 days - back to day 1 14 days 30 days 60 days 90 days 180 days *
8. Amount of life cover you require? £ ? This can cover up to £50000 of your current debts. It will be paid only if you die while you are still paying premiums on the policy.
   *

9. When would you want the cover to start?
   (dd/mm/yyyy) ? If you need to cover your income, your cover can start as soon as your application is accepted. If you want to cover your mortgage payments but your completion date is to be confirmed, you can include a date for your cover to start up to 90 days in the the future.

   day  / month  / year *