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PLAN DETAILS
Type of insurance
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Life Insurance only
Life Insurance with Critical Illness
Mortgage Life Insurance
Whole of Life
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I'd like cover for
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Just me
Me and my partner
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Length of cover
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1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
20 years
21 years
22 years
23 years
24 years
25 years
26 years
27 years
28 years
29 years
30 years
31 years
32 years
33 years
34 years
35 years
36 years
37 years
38 years
39 years
40 years
41 years
42 years
43 years
44 years
45 years
46 years
47 years
48 years
49 years
50 years
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Amount of cover
Please select
£10,000
£15,000
£20,000
£25,000
£30,000
£35,000
£40,000
£45,000
£50,000
£55,000
£60,000
£65,000
£70,000
£75,000
£80,000
£85,000
£90,000
£95,000
£100,000
£105,000
£110,000
£115,000
£120,000
£125,000
£130,000
£135,000
£140,000
£145,000
£150,000
£155,000
£160,000
£165,000
£170,000
£175,000
£180,000
£185,000
£190,000
£195,000
£200,000
£210,000
£220,000
£230,000
£240,000
£250,000
£260,000
£270,000
£280,000
£290,000
£300,000
£325,000
£350,000
£375,000
£400,000
£425,000
£450,000
£475,000
£500,000
£525,000
£550,000
£575,000
£600,000
£650,000
£700,000
£750,000
£800,000
£850,000
£900,000
£950,000
£1,000,000
£1,100,000
£1,200,000
£1,300,000
£1,400,000
£1,500,000
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1
ABOUT YOU
Full name
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My date of birth is
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Have you smoked in the last 12 months?
No
Yes
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2
CONTACT DETAILS
My address is
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My postcode is
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My phone number is
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Telephone number 2
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My email is
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3
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