Policy Type * Life insurance only Critical illness Life and critical illness Cover amount * Period of cover * 1 year 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12 years 13 years 14 years 15 years 16 years 17 years 18 years 19 years 20 years 21 years 22 years 23 years 24 years 25 years Title * Mr Miss Mrs Ms Dr First name * Surname * Date of birth * Daytime phone * Mobile no * Email * House
number * Post code * Has this person smoked any tobacco products in the last 12 months? * Yes No Second applicant required? * No Yes Title Mr Mrs Miss Ms Other First name Surname Date of birth Has this person smoked any tobacco products in the last 12 months? * Yes No