Investment Planning Enquiry

	Life Assurance Enquiry
What level of cover do you require?	£ lump sum
How much can you spend on cover each month?	£ per month
What is the desired term of cover?	For years or until I am years old
Do you require level or decreasing benefit?	Level Decreasing Not Sure?
Would this be used to cover a mortgage?	Yes No
Would you like to add any additional benefits, for example critical illness cover? (If yes, an adviser will contact you to discuss this further)	Yes No
Contact Name:
Date Of Birth:
Gender	Male Female
Have you smoked or used any tobacco products in the last 12 months	Yes No
Contact Number
Email Address
When should we call you?	Morning Afternoon Evening

Life Assurance Enquiry