Impaired Life Annuity Quotations

It is important to answer all questions fully so that an accurate assessment can be made by medical underwriters with regard to your annuity rate. Your data is provided in the strictest confidence and its use is fully covered under the Data Protection Act 1998. This form consists of two steps and the length will vary accoding to which medical conditions have been diagnosed since we will require details on each disclosure.

Section 1: Annuity & Personal Details
Single / Joint Life:		Single    Joint
Size of annuity		£
Indexation		Level3% fixedRPILPI
Guarantee Period		None5 years10 years
Frequency of income payments		MonthlyQuarterlySix MonthlyYearly
Protected/Non Protected Rights		Protected RightsNon Protected RightsBoth Protected and Non ProtectedDon't know
Spouse's Benefit		None33%50%66%100%
		Your details		Your dependant's details
Title		MrMrsMissMsOther		MrMrsMissMsOther
If 'other' please specify
Gender		MaleFemale		MaleFemale
Surname
Forename(s)
Date of birth		(dd/mm/yyyy)		(dd/mm/yyyy)
Nationality
Marital Status		SingleMarried/Civil PartnershipSeparatedDivorcedWidowed		SingleMarried/Civil PartnershipSeparatedDivorcedWidowed
Relationship to the dependant
Present occupation
		Full-timePart-time		Full-timePart-time
If no longer working, previous occupation
Date ceased		(dd/mm/yyyy)		(dd/mm/yyyy)
Postcode
Daytime telephone number
Evening telephone number
E-mail address