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1. Who is to be insured on the policy ?  
   
2. What type of insurance do you require ?  
     
3. How much cover do you want (Sum Assured) ?
£
     
4. How long do you want the cover to last (Term) ?
     Minimum term 30 days
 
     
5. When do you want the policy to start ?  
   
     
6. How many Pre-Existing Medical Conditions are to be    covered ? Total conditions for all insured  
  If the first person insured has two (2) conditions and the second person one (1) condition, select three (3)
     
7. Do you, or anybody to be insured on the policy have a    Hazardous Occupation ?  
     
8. Do you or, anybody to be covered on the policy work    or live in a Hazardous Location or Country ?  
     
9. If necessary please use the box below to enter any other details about the type of insurance you want
     
     
     
     
 
 
Disclosure : It is the responsibility of the person insured on the policy and / or the policy holder to ensure that all material information is disclosed at the point of application. If you are at all uncertain about whether any information or condition is material then you must disclose it. Failing to disclose material information could result in your policy being cancelled and claims not paid.
 
 
Specialist Life Insurance Solutions  |  Platinum Financial "good old fashioned personal service via the internet"
 
 
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Telephone : 020 33 55 4831                   Fax : 0871 277 1422                    Email : info@platinumifa.co.uk

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