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 according to which medical conditions have been diagnosed since we will require details on each disclosure.

Section 1: Annuity & Personal Details

Single / Joint Life:      
Size of annuity£
Indexation
Guarantee Period
Frequency of income payments
Spouse's Benefit
Your detailsYour dependant's details
Title
If 'other' please specify
Gender
Surname
Forename(s)
Date of birth   (dd/mm/yyyy)   (dd/mm/yyyy)
Nationality
Marital Status
Relationship to the dependant
Present occupation
If no longer working, previous occupation
Date ceased   (dd/mm/yyyy)   (dd/mm/yyyy)
Postcode
Daytime telephone number
Evening telephone number
E-mail address