Insure Your Income

1

Which of the following do you want to insure against?* This field is required.

Illness

Accident / Injury

Unforeseen future event

All of the above

2

What is your occupation?* This field is required.Start typing and choose from the list of occupations. You must select a job from the dropdown. If your exact job title is not available please choose the closest variant possible.

3

Which best describes your current employment status?* This field is required.

Employee

Self Employed

Company Director

4

What's your date of birth?* This field is required.

5

Which county do you live in?

6

gclid

7

What is your gross annual salary?* This field is required.

Under €40,000

€40,000 - €60,000

€60,000 - €100,000

€100,000+

8

Do you smoke?* This field is required.* Have you smoked in the past 12 months

Smoker

Non-Smoker

9

Male or Female?

Male

Female

10

utm_source

11

In the past 5 years have you been treated for any serious health conditions like heart problems, liver problems, diabetes, MS, or cancer?* This field is required.

YESNO

12

What's your first name?* This field is required.

13

What's your email address?* This field is required.We'll email you your insurance status

14

I agree to the Insure Your Income privacy policy* This field is required.By ticking this checkbox, you agree to and confirm that you have read our Privacy Policy

I agree