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Specialist home insurance help - Get a Quote & Information
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Specialist home insurance help
A Trading Style of Platinum Financial Consulting

Authorised and Regulated
By

   
THE FINANCIAL CONDUCT
AUTHORITY
FSA Registration No : 227014  
     
 
 

Please use this form to tell as much about you and your circumstances.

Please Remember : If you fail to disclose a material fact, you could run the risk of having your insurance cancelled and / or have a claim refused.

If you are in any doubt about whether a fact is material or not, please disclose it.

 
About our website security
      Only enter partners details if you want them covered on your policy.  
 
   
Title :  
     
Forename :  
     
Surname :  
     
Sex :  
     
Date of Birth :  
(dd/mm/yyyy)  
     
Address    
     
Home Phone :  
     
Work Phone :  
     
Mobile Phone :  
     
Email :  
     
     
 
   
Title :  
     
Forename :  
     
Surname :  
     
Sex :  
     
Date of Birth :  
(dd/mm/yyyy)  
     
Address    
     
Home Phone :  
     
Work Phone :  
     
Mobile Phone :  
     
Email :  
     
 
 
Please give us as much information about the cover you require and your reasons for wanting it. We have included a free text box for you to use if you wish.
     
Type of Insurance :  
     
Type of Cover :  
     
Reason for Cover :  
Please use box below to give more information    
     
Period of Cover Required (Term):    Years
     
Amount of Cover Wanted (Benefit) :   £
     
Any other relevant information    
     
     
 
      Only enter partners details if you want them covered on your policy.  
 
     
Have you smoked in the past 12 months ?  
     
If yes - what do you smoke ?  
     
If yes - how many per day ?  
     
How many units of alcohol do you consume in the average week ?
   

1 glass of wine or a shot of spirits = 1 Unit, 1 Pint of beer = 2 Units
     
What is your height ?  
     
What is your weight ?  
     
What is your waist size ?  
     
What is your dress size ?
[if applicable]
 
     
In what areas do you need our help ?
Please tick all that apply

You will have a separate questionnaire for each category
     
     
Overweight / High BMI  
   
Pre-Existing Medical Condition
   
Hazardous Occupation
   
Hazardous Hobby
   
 
     
Have you smoked in the past 12 months ?  
     
If yes - what do you smoke ?  
     
If yes - how many per day ?  
     
How many units of alcohol do you consume in the average week ?
   

1 glass of wine or a shot of spirits = 1 Unit, 1 Pint of beer = 2 Units
     
What is your height ?  
     
What is your weight ?  
     
What is your waist size ?  
     
What is your dress size
[if applicable]
 
     
In what areas do you need our help ?
Please tick all that apply

You will have a separate questionnaire for each category
     
     
Overweight / High BMI  
   
Pre-Existing Medical Condition
   
Hazardous Occupation
   
Hazardous Hobby
   
 
     
     
Platinum Financial Consulting, The Old School House, East End Road, Bradwell-on-Sea, Essex, CM0 7PY
Telephone : 08450 55 95 65               Fax : 0871 277 1422          Email : help@platinumifa.co.uk