Aisa Direct

Term Life and Critical Illnes Cover

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

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?

Amount of cover £

Over what term?

Application

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Date Of Birth:

Gender:

Smoker:

Second person (Optional)

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Contact details

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Lifestyle declaration or Dangerous Pursuits

Please declare any hazardous activities:

Lifestyle ratings:

Anything else to declare? Yes No

Do you want Income Protection?

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Life insurance and critical illness cover