Term Life and Critical Illnes Cover

Select the type of Life Insurance and/or Critical Illness cover you require:*

Life Insurance Only (which includes Terminal Illness Cover at no extra cost) Critical Illness Cover Only One policy covering both Life Insurance Cover AND Critical Illness Cover One policy covers Life Insurance Cover OR Critical Illness Cover, whichever first

If you select ' Life Insurance OR Critical Illness Cover' please note that this will give Life OR Critical Illness cover on a 'first event' basis. i.e. Life cover will NOT continue after payment for Critical Illness. If continuing cover is required after a Critical Illness then select 'Life Insurance AND Critical illness Cover'.

Is this policy to protect the decreasing liability of a repayment mortgage? Select Yes No

Amount of cover £ £

Over what term? Select   5 years  6 years  7 years  8 years  9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years19 years20 years21 years22 years23 years24 years25 years26 years27 years28 years29 years30 years

Second person (Optional)

Name:

Date Of Birth: -- 01020304050607080910111213141516171819202122232425262728293031 -- 010203040506070809101112 ---- 1996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912

Gender: Male Female

Smoker: No Yes

Password

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Password: (note it down! min 6 characters)

Contact details

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Day Phone:

Mobile Phone:

E-mail:

Lifestyle declaration or Dangerous Pursuits

Lifestyle ratings:
--- please select --- None Declared Live Abroad Ongoing health issues Health Issues in last 10yrs Dangerous Work Activities

Anything else to declare? Yes No

Do you want Income Protection?

Yes No

How did you find out about AISA?

Not specified
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Referral from friend or colleague

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Do you require any further financial advice? No Yes

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