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Critical Illness Enquiry Form

Required fields are marked as Complete the enquiry form below with your requirements and we will be in touch shortly.

Enquiry Form

Your Name

Your Email

Telephone Number

Mobile Number

How would you like to be contacted initially? Choose one of the two options above

Sex

Male

Female

Do you smoke?

Yes

Date of Birth For example, 01/06/1970

Benefit Level Required (per month)

Cover Required (Check one box)

LTA (Level Term Assurance)

DTA (Decreasing Term Assurance)

WOL (Whole Of Life)

FIB (Family Income Benefit)

Amount of cover required (In 000's)

Term (in years)

Inflation Proofed?

Yes

Waiver of premium?

Yes

If joint cover is required, please enter partner's details below, else click on 'Send'.

Partner's Name

Date of Birth For example, 01/06/1970

Sex

Male

Female

Do you smoke?

Yes

Waiver of premium?

Yes

Comments

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Please Note: Financial advice on these pages is given by ContractorMoney, which is a trading name of Contractor Financials Ltd and is regulated and authorised by the Financial Services Authority.

Click here for Important Legal Information which should be read. Click here for a copy of our Private Client Agreement. Click here for a copy of our Initial Disclosure Document.

The FSA do not regulate some forms of insurance / protection. Certain life policies have an investment element. It is important to understand that these investments are longer term in nature and that the value of investments and income from them can fall as well as rise. Past performance is also no guarantee of future performance.