Click n go Insurance Broker

Single / Joint Policy Single Joint

Life Insurance Yes No

Accident, Sickness & Unemployment Yes No

How much cover do you need? [Please Select] £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 £205,000 £210,000 £215,000 £220,000 £225,000 £230,000 £235,000 £240,000 £245,000 £250,000 £255,000 £260,000 £265,000 £270,000 £275,000 £280,000 £285,000 £290,000 £295,000 £300,000 £325,000 £350,000 £375,000 £400,000 £425,000 £450,000 £475,000 £500,000 £550,000 £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 £1,600,000 £1,700,000 £1,800,000 £1,900,000 £2,000,000 £2,100,000 £2,200,000 £2,300,000 £2,400,000 £2,500,000 £2,600,000 £2,700,000 £2,800,000 £2,900,000 £3,000,000

What is your preferred budget? [Please Select] £0 - £25 £25 - £50 £50+

How much are you paying now...Protection Cover? [Please Select] £0 - £25 £25 - £50 £50+

Critical Illness Yes No

Mortgage Protection Yes No

Home Insurance Yes No

How long do you need the cover for? [Please Select] 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

How much are you paying now...Home Insurance? [Please Select] £0 - £25 £25 - £50 £50+

First Name

Surname

Job Title

Monthly Mortgage Payment (£)

Date of Birth

Sex Male Female

Basic Salary [Please Select] £10,000 - £15,000 £15,000 - £20,000 £20,000 - £25,000 £25,000 - £30,000 £30,000 - £35,000 £35,000 - £40,000 £40,000 - £45,000 £45,000 - £50,000 £50,000 - £55,000 £55,000 - £60,000 £60,000 - £65,000 £65,000 - £70,000 £70,000 - £75,000 £75,000 - £80,000 £80,000 - £85,000 £85,000 - £90,000 £90,000 - £95,000 £95,000 - £100,000 £100,000+

Have you smoked in the last 12 months? Yes No

Home Tel No

Mobile Tel No

Email Address

Address

Post Code