Get a Quotation

Please complete the form below and we can start working on your quotation – we will then contact you with details of the cover you require and the price you are likely to pay

		First Applicant	Second Applicant
Title:
Name:
Address:
Postcode:
Email:
Telephone Number:
Alternate Number:
Preferred Contact Method:
Best Time to Contact You:
Date of Birth:		/ / dd/mm/yyyy	/ / dd/mm/yyyy
Height:		feet inches Or metres	feet inches Or metres
Weight:		stones pounds Or kilograms	stones pounds Or kilograms
Do you Smoke?
Basis of Cover (single or joint):
How much Cover do you require?	£
Reason for Cover?
Number of years cover is Required?
Level or Decreasing?
Do you have a pre-existing Condition?
Please give details:
Family History of the Serious Medical Condition: i.e. heart attack, cancer, stroke, etc.
Please give details:
Do you have a Hazardous Occupation or Hobby?
Please give details:
Has any application for Life Insurance been declined, postponed, withdrawn or accepted on special terms (e.g. an increase in premium)? OR are you awaiting a decision on a current application?
Please give details:
How did you Find Us?
Additional Information:
Notes:
You voluntarily choose to provide personal details to us via this website. Personal information will be treated as confidential by us and held in accordance with the Data Protection Act 1998. You agree that such personal information may be used to provide you with details of services and products in writing, by email or by telephone. Please check this box to indicate your agreement

Life Cover For All LLP (Registered in England under company Reg No OC359631) is an Appointed Representative of Access Wealth Management, Station House, Station Road, Wylam, Northumberland, NE41 8HR which is authorised and regulated by the Financial Services Authority