Moneysworth® UK Life Insurance Quote Form

Any quotation issued is based on the information your provide below, and is for information only. We offer no advice or recommendation as to the product's suitability given your specific circumstances. Please note that all quotations are produced on the assumptions that you will be the policy owner and the life assured and that you require the cheapest policy. If you do not want a quotation on this basis, please contact us to discuss your requirements.

Title	Mrs Ms Miss Mr Dr	Name Surname *
Sex	Male Female
Address	* *
Postcode	*
Telephone: (Work)	* (Home) (Mobile) (only to be used in connection with this enquiry)
Email Address	*
Date of Birth	*(DD/MM/YYYY)
Have you smoked in the last 12 months? Yes, or No*
Occupation	No hazardous occupation As a sports professional Fishing industry In the armed forces Heavy Lifting Heavy Machinery Oil or gas production industry Pilot Rally Driver Under ground Under water Working With explosives Working at heights over 40 feet for more than 25% of the time Working in hazardous environment Other *Other: *
Play Sport	No sporting activities Abseiling Aviation Sport Caving Climbing Sports Diving Equestrian Sports Flying other than as a fare paying passenger Hang-Gliding Motor Sport Motorcycle Sport Mountaineering Parachuting Pot-Holing Powerboat Racing Racing Rock Climbing Sailing Sports Professional Sky Diving Other *Other: *
Health Problems	No health problems Angina Anxiety Asthma Bladder Disease Bowel Disorder Breast Cancers Bronchitis Chest Pain Circulation Disorder Colitis Depression Diabetes Epilepsy Heart Disorder Hepatitis B / C High Blood Pressure HIV / Aids Hypertension Kidney Disease Liver Disorder Mental Disorder Nervous Disorder Multiple Sclerosis Paralysis Multiple Sclerosis Raised Cholesterol Stomach Disorder Stress Stroke Other *Other: *
Has applicant 1 been declined elsewhere? Yes No
Do you want to consider quotes that have reviewable premiums? Yes, or No*[Help]
Is Joint Cover required? Yes, or No
Second Applicant:
Title	Mrs Ms Miss Mr Dr First Name Surname
Sex	Male Female
Date of Birth
Has your partner smoked in the last 12 months? Yes, or No
Occupation	No hazardous occupation As a sports professional Fishing industry In the armed forces Heavy Lifting Heavy Machinery Oil or gas production industry Pilot Rally Driver Under ground Under water Working With explosives Working at heights over 40 feet for more than 25% of the time Working in hazardous environment Other *Other: *
Play Sport	No sporting activities Abseling Aviation Sport Caving Climbing Sports Diving Equestrian Sports Flying other than as a fare paying passenger Hang-Gliding Motor Sport Motorcycle Sport Mountaineering Parachuting Pot-Holing Powerboat Racing Racing Rock Climbing Sailing Sports Professional Sky Diving Other *Other: *
Health Problems	No health problems Angina Anxiety Asthma Bladder Disease Bowel Disorder Breast Cancers Bronchitis Chest Pain Circulation Disorder Colitis Depression Diabetes Epilepsy Heart Disorder Hepatitis B / C High Blood Pressure HIV / Aids Hypertension Kidney Disease Liver Disorder Mental Disorder Nervous Disorder Multiple Sclerosis Paralysis Multiple Sclerosis Raised Cholesterol Stomach Disorder Stress Stroke Other *Other: *
Has applicant 2 been declined elsewhere? Yes No
Type of Quote Required:
Is this assurance to cover a mortgage? Yes, No (Hint - 'Level term' life assurance is often used for interest only mortgages and 'Decreasing term' life assurance is often used to cover the decreasing balance of a repayment mortgage)
If 'Yes', please provide your lender's name

Please fill in your quotation below:

	Quote 1 *
Type of Cover (see definitions in new window)	Select... Level Term (Includes Terminal Illness) Level Term (Includes Terminal and Critical Illness) Decreasing Term (Includes Terminal Illness) Decreasing Term (Includes Terminal and Critical Illness) Keyman Insurance Only * Important Info
Amount of Cover in £	*
Number of Years	*

How did you find Life Assurance UK: Please Select... Daily Express Daily Mail Daily Mirror Daily Star Financial Times Find First Home From A Friend Guardian Investors Chronicle Mail on Sunday Moneywise Mortgage Adviser Mortgage Magazine News of the World Personal Finance Search Engine Sun Newspaper Sunday Express Sunday Mirror Sunday Telegraph The Times Other
If 'other' - please specify where here :

*Mandatory field. Please

I would like a quote by mail and/or email and/or live in screen in a few seconds

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