Personal Income Protection

	Personal Income Protection Enquiry Form
Use this form if you are considering personal income protection insurance, sometimes refered to as permanent health insurance (PHI), or if you wish to enhance the benefits of a company scheme. Rates can be reviewable or guaranteed and ideally are based on an 'own occupation' definition of disability.
Thank you for your enquiry. Please complete the enquiry form below

Name applicant
Date of birth
Sex	male female
Smoker	non-smoker smoker
Address
Post Code
Telephone (day)
Telephone (evening)
Facsimile
Email
Job Description
Business miles per year (car) or frequent overseas visits.
How long would you employer continue to pay your salary in the event of ill health
If your employer provides any incapacity benefit, please give details
Are you a member of a State Occupational Pension Scheme i.e. Teacher, Local Government, Civil Service, Health Service etc.
	Yes No
Years of service within your State Occupational Scheme
Have you purchased any Added Years?	Yes No
Expected retirement age
Current Salary
Benefit required Ł per annum	Maximum or other (if 'other' please state how much)
Guaranteed / Reviewable Rates? My preferred option is for a :-	Guaranteed rate - slightly higher initial premium but guaranteed not to increase during the term of the plan Reviewable rate - lower initial premiums but may increase in later years Please provide comparative quotes
Deferred period
How would you prefer to receive your quote?	... email me ... telephone me ... by post with a brochure and application form
Brochures and application forms are available on request.
Please note any other comments or questions:
Home Page