Get a Quote

Individual Term Life Plan

Please complete the enquiry form below. We need this information to provide you with the most suitable life cover quote.

Once you have submitted the form to us, we aim to provide you with an indication of the cost within 2 working days. Please note that our working days are Monday to Friday.

The information you provide to us is treated in the strictest confidence and is only passed to the Insurance Company who we approach to provide a quote.

1st Life

2nd Life

Title

Title

First Name

First Name)

Surname

Surname

Date of Birth

(dd/mm/yyyy)

Date of Birth

(dd/mm/yyyy)

Have you smoked or used any nicotine products in the last 12 months?

 Yes No

Have you smoked or used any nicotine products in the last 12 months?

 Yes No

Occupation

Occupation

Nationality

Nationality
 

Contact Details

Address 1

Address 2

City

Postcode

Country of Residence

Telephone No.

Email
 

Cover Details

How much would you like to be insured for?:

Term of Policy:

 5 Year 10 Year 

Please state whether joint life/first death or two separate policies if more than 1 applicant

 Joint Life Two Separate Policies 

If permanent disability cover is required, please state capital sum.

Please type letters from image

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N.B. Kindly note that joint life first death policies mean that if one partner dies, the other is then left without cover. If you require continued cover after the death of one partner please select two separate policies

Thank you for completing our Individual Term Life insurance quote form.

Please click on the submit button to send the form to us.

+44 (0) 118 970 3782
Mon to Fri, 9:00am - 5:00pm