Is this a single or a joint policy?
Please Select
Single
What are your initials please?
*
Plan/Policy number
*
In the event of a payout whilst you are still alive due to terminal illness would you like to payment made to you or to your beneficiary?
*
Please Select
To Me
To My Beneficiary
Your full name
*
Address
*
Street Address
Street Address Line 2
City
County
Post Code
Name of second person insured
First Name
Last Name
Do they live at the same address?
Please Select
Yes
No
Address of second person insured
Street Address
Street Address Line 2
City
County
Post Code
How many trustees apart from yourself? (Max 3)
*
Please Select
One
Two
Three
Name of 1st Trustee
*
First Name
Last Name
Date of birth of 1st trustee
*
-
Day
-
Month
Year
Date
Is Address of Trustee same as yours?
*
Please Select
Yes
No
Address of 1st trustee
*
Street Address
Street Address Line 2
City
County
Post Code
Email of 1st trustee
*
example@example.com
Name of 2nd Trustee
*
First Name
Last Name
Date of birth of 2nd trustee
*
-
Day
-
Month
Year
Date
Is Address of 2nd Trustee the same as any of the other trustees?
*
Please Select
Yes, Mine
Yes, Trustee 1
No
Address of 2nd Trustee
*
Street Address
Street Address Line 2
City
County
Post Code
Email of 2nd trustee
*
example@example.com
Name of 3rd Trustee
*
First Name
Last Name
Date of birth of 3rd trustee
*
-
Day
-
Month
Year
Date
Is Address of 3rd Trustee the same as any of the other trustees??
*
Please Select
Yes, Mine
Yes, Trustee 1
Yes, Trustee 2
No
Address of 3rd Trustee
*
Street Address
Street Address Line 2
City
County
Post Code
Email of 3rd trustee
*
example@example.com
How many beneficiaries are you naming? (Max 4)
*
Please Select
One
Two
Three
Four
Name of 1st beneficiary
*
First Name
Last Name
Date of birth of first beneficiary
*
-
Day
-
Month
Year
Date
Name of 2nd beneficiary
*
First Name
Last Name
Date of birth of 2nd Beneficiary
*
-
Day
-
Month
Year
Date
Name of 3rd beneficiary
*
First Name
Last Name
Date of birth of 3rd beneficiary
*
-
Day
-
Month
Year
Date
Name of 4th beneficiary
*
First Name
Last Name
Date of birth of 4th beneficiary
*
-
Day
-
Month
Year
Date
How many witnesses would you like? One can witness all trustees
*
Please Select
One
Two
Three
Four
Please type name and address of 1st Witness to Witness your signature
*
Email of 1st Witness
example@example.com
Please type name and address of 2nd Witness to witness first trustee
*
Email of 2nd Witness to witness 1st trustee
example@example.com
Please type name and address of 3rd Witness to witness 2nd trustee
*
Email of 3nd Witness to witness 2nd trustee
example@example.com
Please type name and address of 4th Witness to witness 3rd trustee
*
Email of 4th Witness to witness 3rd trustee
example@example.com
The day of the month today
*
The month
*
The year
*
Are you happy with everything? Please submit either answer
Please Select
Yes - Please send for signatures
No - Please call me to assist
Preview PDF
Submit
YN1
YA1
SN1
SA1
T1
T1a
T1d
/
Month
/
Day
Year
Date
T1e
example@example.com
T2
T2a
T2d
/
Month
/
Day
Year
Date
T2e
example@example.com
T3
T3a
T3d
/
Month
/
Day
Year
Date
T3e
example@example.com
Plan number
First name
Second name
Survivorship clause
Retained Fund First name
Retained Fund Second name
Gifted Fund First name
Gifted Fund Second name
B1
BD1
/
Month
/
Day
Year
Date
B2
BD2
/
Month
/
Day
Year
B3
BD3
B4
BD4
Name of settlor
11111111Name and address of Witness
ignoreame of second Settlor
ignoreName and address of Witness to second insured
Name of 1st trustee
22222222Name and address of Witness of 1st trustee
Name of 2nd trustee
Signature of Witness
33333Name and address of Witness of 2nd trustee
Name of third additional trustee
444444Name and address of Witness of 3rd trustee
Should be Empty: