Protection Questionnaire

Please complete the form below online, print using the tab on your browser and send it to us at:

Heritage Financial Services, Newnham House, 90A Pyle St, Newport, Isle of Wight, PO30 1UJ

* Required Field

Section 1 - Personal

Who is going to make the application (policyowner)?

Applicant

* *

*

* *

Section 2 - Whose life is to be insured?

Ist life assured

* *

* Occupation * Income (£)

We need to know your income because life offices impose restrictions on how much life cover you can have in relation to your income.

2nd life assured (joint lives)

Occupation Income (£)

We need to know your income because life offcies impose restrictions on how much life cover you can have in relation to your income.

Section 3 - Existing protection

Do you have any existing life assurance?

Section 4 - Protection needs

Mortgage

Do you want to protect your mortgage?

If Yes, what type? Do you have any existing life assurance?

If Yes, how much? (£) Remaining policy term - years

Other loans

If Yes, the amount outstanding (£)

Income

..

(maximum 10 x income)

How long would you like the income to be paid? If Yes by how much?

Do you have any existing life assurance to cover income?

If Yes, how much? (£) Remaining policy term years

To insure your life on death? and or to insure on diagnosis of a critical illness?