Income Protection Quote

Salary Before Tax (£)

Is this

per month or per year?

Monthly benefit required (£)
(Max 70% of salary before tax)

Preferred waiting period

4 Weeks 8 Weeks 12 Weeks 6 Months 12 Months 24 Months

This is the period of time before the income protection policy start to pay benefits.

Preferred retirement age

50 55 60 65

Occupation

Details of any manual duties

How many business miles do you do in a year?

Not including travel to and from work.

Title

Select Mr Mrs Miss Ms Other

Initials

Surname

Contact Phone

Email

House Name / No

Postcode

Gender

Male Female

Date of Birth

Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec / Year 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901

Have you smoked in the last 12 months?

Yes No

Have you smoked any tobacco products within the last 12 months, or used any products containing nicotine?

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