Mortgage Protection Plan

 

First Applicant

Second Applicant

..Surname
...Surname
..Title
...Title
..First Name
...First Name
 Date of Birth
19
..Date of Birth
19
..Marital Status
.Marital Status
Home Tel no.
Home Tel no.*.
..Work Tel no.
Work Tel no.*
Mobile Tel no.
Mobile Tel no.*
..Address1
Address1*
Address2
Address2*
Town
Town*.
County
County*
Postcode
Postcode*
Email
Email *
 
    * If different from applicant 1
       

2 Your Work

First Applicant

Second Applicant

Occupation
Occupation
Employment Status
Employment Status
Time in present employment
years
Time in present employment
years
Annual income
£
Annual income
£
   

3 About your mortgage

   

What monthly benefit do you require? (this should be limited to mortgage repayment, buildings insurance and related life cover)

£
per month
Joint Borrowers - please indicate how you would like the Monthly Benefit split between you i.e. 50/50, 80/20, 40/60 etc. N.B. Must total 100%.
First person insured (Applicant 1)
Second person insured (Applicant 2)
On what date would you like the cover to start? ..
20
..
Do you require a monthly or single premium policy? (please select)......
 

4 About Your Circumstances

   
   
First insured
Second insured
1 Are you now, and have you been for the past 6 months in continuous Permanent Employment, Contract Employment or Self Employment for more than 16 hours per week?            
2 Have you at any time during the last 12 months been registered unemployed?            
3 Do you know of any impending Unemployment, which may affect you?            
4 Have you consulted a doctor or consultant in the last 12 months other than for minor ailments?            
5 Has any application for Life or Disability Insurance on your life ever been postponed, declined or withdrawn or had any special terms imposed?            
6 Are you aware of any impending Disability, which may affect you?            
7 Are you in arrears with any mortgage or other debt repayments?            
 
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