Online Consultation

1
Name* This field is required.
Mr.
Mr.
Mrs.
Ms.
Miss.
Dr.
Sir.
Prefix
First Name
Last Name
2
Birth Date* This field is required.
Day
Month
Year
3
Are you a Smoker (Inc. Vaping)* This field is required.To be classed as a non-smoker you must not have used any tobacco products in the last 12 month.
Yes
No
Vapes Only
Cannabis Smoker
Including e-cigarettes and nicotine replacement products such as patches or chewing gum.
4
Phone Number* This field is required.
5
E-mail* This field is required.
example@example.com
6
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Post code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Date moved in Date of residency Or time at address Years at address Months at address
8
About your StatusPartners details can help identify length of financial responsibility or the Beneficiary of the Policy
Please Select
Please Select
Male
Female
Gender
Please Select
Please Select
Single
Married
Civil Partnership
Partnered / Relationship
Divorced
Widowed
Marital Status
Spouse or Partners Details
Spouse or Partners Date of Birth
9
Residency SatusResidence and Properties
Please Select
Please Select
Private Tenant / Renting
Living with Parents
Living with Friends or Relatives
Owner Occupier - Mortgage
Owner Occupier - Without Mortgage
Council Tenants or Housing Association
Provided by Employer
Other
Residential status
No - Don't Own
Yes - Own
Yes - Purchasing / Need a Mortgage Broker
Yes - Own Buy to lets / Portfolio Landlord
Do you own or are you purchasing any properties
10
Nationality and Residency * This field is required.We are unable to cover non Uk Residence
Nationality
Please Select
Please Select
Yes
No
Are you a Uk resident
11
About your Occupation ? * This field is required.
Please Select
Please Select
Employed
Self employed / Sole trader
Company Director
Unemployed
Retired
Employment status
Occupation
Employer / Company Name
12
About your income and Outgoings * This field is required.Include State Benefits and Capital Gains income if applicable
Annual Gross Income (Before tax)
Monthly Net Income ( After tax)
Total Monthly Outgoings
Net monthly surplus (Disposable Income)
Affordable allowance for your monthly payments
13
Do you have a sick-pay package with your Employer?Employers Benefits:
0 Days Pay
1 week Pay
2 weeks Pay
4 weeks Pay
8 weeks Pay
12 weeks Pay
6 Months Pay
12 Months Pay
other
Length of time you would receive an income by your employer if sick and unable to work
14
Residential Mortgage Details click next if not applicable
Who is the Lender / Bank
Please Select
Please Select
Capital Repayment
Repayment
Interest Only
Split (Part interest and part repayment)
Other
Mortgage Payment Option?
What is the current property value
Original purchase price
What is your monthly mortgage payments
How much is the outstanding mortgage balance
Remaining term of Mortgage
What is your current interest rate
15
Do you have any Liabilities? Car Finance, Credit cards, Loans
Please Select
Please Select
Loans
Credit Cards
Car Finance
Debts
Other
Types of Liabilities
Total balance of your overall outstanding debts
16
Full Name and date of Birth of your youngest Dependant?Anyone who depends on you financially
This can include Partners, Elderly relatives, Disabled Persons and Children
What is the Date of Birth of your youngest Dependant?
17
What is your Height and WeightPlease chosen your preferred metrics
Hight: Meter-m / Centimeter-cm
Hight: Foot-Inch -ft-in
Weight: Stone-st - Pound-lb
Weight: Kilograms-Kg
18
Whats is the name of your registered General Practitioner (GP) Surgery
Name of Medical GP Sugery
Surgery Address
Post code
Sugery Contact details
19
What packages are you interested in?* This field is required.select comprehensive for a full range of options
Not Sure (Need Advice)
Mortgage Finance
Fully Comprehensive
Life Insurance
Income Protection
Critical Illness Cover
Family Income Benefit
Whole of Life
Private Medical Insurance
Building and Content Cover
Mortgage Insurance
Landlords Insurance
Funeral Plan
Over 50's Life Insurance
Business Protection
Public Liability Or Indemnity Cover
Relevant Life
None Medically Underwriting Cover
Other
20
Any health conditions, Diagnosis or prescribed medications?This will help determine the most appropriate providers and products tailored to you.
any relevant information about your health, Please include dates if relevant
21
Additional InformationAdditional information to consider when making your recommendations.
22
Appointment* This field is required.Best contact date and time
23
How did you hear about us?Please insert the name of the person who referred You if applicable.
Affiliate Partner or Referral Agent
Social Media
Online
Advertisements
Friends & Relatives
Other
Select how you find out about our services
Insert the affiliate code, affiliate partner details or the Person who referred you if applicable
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