Permanent Health Insurance (PHI)
Illustration/Application Request Form
Not got time online?
Just click
and post the form back to us.
Our address is given below.
More about us...
Your application is secure
Your application is digitally encrypted
Please complete these details for a no-obligation illustration. You are under not committing to anything at this stage and all information remains confidential. Check our privacy statement

We will post the illustration to the address you provide.

This service is available to UK residents only.

A few details about you . . .
Required fields are in bold
Title: Title if 'Other':
First name(s):
 Surname:
Date of birth: (dd/mm/yy)
Gender:
Employment:
 Tick if you are a smoker
  Tick if you particiapte in any hazardous pastimes, hobbies or sports

Please select how you found our website:  
If search engine, link, paper, magazine or "other" please say which:

 What you are interested in . . .

 Your choice of insurance company:

 Click here for examples
* You must choose a specific company, "any" is not valid!
* We are not able to discount companies that do not pay commissions such as Virgin, Tesco PF, Barclays Life, Halifax Life, Marks & Spencer and NFU Mutual. IF YOUR RESEARCH MAKES ONE OF THESE YOUR FIRST CHOICE, YOU MIGHT FIND THAT OUR QUOTE FOR THE SECOND CHEAPEST COMMISSION-PAYING COMPANY IS CHEAPER AFTER THE REBATE.
Cover required: £
To what age should the cover last: 
Frequency of benefit payments required:  
Deferred period before benefits are paid:
Is the level of cover to be:  throughout the term
Are the benefits to be: throughout the term
Premium frequency: 
Tick if you would like Waiver of Premium benefit   
Tick for a "no-rebate" illustration to compare against our "rebated" one
(so you can see how much you benefit) 
Your occupation:
(Please be precise)
Tick if you work at heights or with high voltage electricity or drive more than 12,000 business miles per year
Your gross annual income: £
If you need to, please use the 'additional information' field below.


Your contact details . . .
Email address
Address line 1
Address line 2
Town or city
County
Postcode

Telephone ~ Day: Evening: Mobile:

My preferred method of contact in case of query is:

Please use this space for any additional information you wish to provide:

Tick if you do not wish to be contacted about special offers for financial products which may be of interest to you

If you print the form, please complete it and post to: