Life Insurance Questionnaire

To help us match your application with the most suitable insurer, and to get the best value quotes and product features, please answer the following questions as clearly and accurately as possible.

Insurers use this information to assess your application, so providing complete and honest answers will help ensure the process runs smoothly and avoids delays. Some questions may feel personal, but each one is necessary to support your enquiry and application.

Please leave blank:

Your Name:

Your Phone Number:

Your Email Address:

>> Click here to confirm your enquiry

Your enquiry (please tick all that apply):

personal / family life insurance mortgage protection life insurance business protection - (includes keyperson cover, group schemes, shareholder protection) Trusts planning other (please confirm in the notes section below)

>> Click here to provide your height, weight ...

Date of Birth:

Height:

Weight:

Sex:

>> Click here to confirm your occupation details

Your Employer's Name:

Your job title:

Your annual salary / income:

How did you find our website?

>> Click here to confirm your smoking and alcohol status

Do you smoke or have you in the last 12 months? (This includes Nicotine replacements, Tobacco Products & Electronic Cigarettes):

If "yes", what type (e.g. tobacco, vape etc)? And if cigarettes, how many each day?

If "no", have you ever smoked in the past? If so, when did you stop?

How many units of alcohol do you drink per week? Enter a number (A pint of low strength beer or a standard size glass of wine is typically around 2 units) Enter a number:

In the last 5 years have you taken any recreational drugs such as Cannabis, Cocaine, Ecstasy, Heroin etc?

>> Click here to confirm your pursuits and activities

Do you take part in any of the following?

Underwater diving Mountaineering or rock climbing Flying (other than as a fare paying passenger), hang gliding or paragliding Motorcar or motorcycle sport Parachuting, skydiving or BASE jumping None of these Do you ride a motorcycle, scooter or moped on the road? During the last 5 years have you been disqualified from driving for a motoring offence or convicted of careless or reckless driving?

Do you currently ride a motorbike?

Have you ever been banned from driving?

>> Click here to confirm your travel information

During the last three years, have you spent more than 90 days in total in Africa, the Caribbean, Russia, Thailand or Ukraine:

Are you currently living outside of, or during the next 12 months do you intend to spend more than 30 days outside of:

>> Click here to confirm your GP information

I consent for the relevant insurer to contact my GP surgery to request medical information pertinent to my application *:

GP Surgery - Name and Location:

Notes:

You can upload supporting information documents here (max 3mb):

Our office address

Assured Protect

The Colchester Business Centre

1 George Williams Way

Colchester

Essex CO1 2JS

BY CAR; We have a large free car park, accessible via the double gates at the side of the office building.

BY TRAIN; We are just a few minutes walk from Colchester Town railway station

Map and Direction Google Maps Link

Life Insurance Questionnaire; Complete the questionnaire below and send us your enquiry, and one of the team will 'phone you back.