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Fast Track Assessment for previously declined cases

Please use this form if you have ever been "declined/refused" life insurance cover by an insurance company, or consider your existing premium too high for the cover offered. Once you submit this completed form we will give an opinion as to whether we expect to be able to offer terms and then advise you how to proceed.

It is important to remember that, despite all our efforts, some cases will remain uninsurable and by using this FAST TRACK procedure we should be able to identify these at an early stage without the need to complete a full application only later to be declined. This process will enable us to conduct a Fast Track assessment of you case. Only then will we invite a full application.  Please use this form if you have ever been "declined/refused" life insurance cover by an insurance company. Once you submit this completed form we will give an opinion as to whether we expect to be able to offer terms and then advise you how to proceed.

For a fast and professional service, please complete the form below and we'll do our best to help you at your convenience.
Fields marked with a * are required
Choose your area of interest: 
*Application type:

Single lifeJoint life

 
Personal Details.... SELF
Title:
First name(s):
Surname:

Home address:
Post code:
*Telephone number:
Mobile number:
Fax number:
*Email address:
*Confirm email address:
Date of birth:
Marital status:
Have you smoked or used any tobacco or nicotine products within
the last 12 months:
Yes   No
UK resident:
Domicile:
National Insurance No:
Sex:
Male   Female
Height:
Weight:
Policy required: Term Assurance Whole Life
Term / years to age:
Premium if rated:
Sum assured
Life offices applied to before or used so far:
Was the application previously: DeclinedRatedPostponed
Approximate date application declined / rated (dd/mm/yyyy):
Brief outline of medical condition / occupation / past time:
For medical condition please state current or past medical treatment. Also state any investigations or operations made plus the frequency of any follow ups / check ups needed:
Prior to the completion of this form we have read and understood the IDD & TERMS of BUSINESS contained on this website
Yes No
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
 

Personal Details.... PARTNER
Title:
First name(s):
Surname:

Home address:
Post code:
Telephone number:
Mobile number:
Fax number:
Email address:
Confirm email address:
Date of birth:
Marital status:
Have you smoked or used any tobacco or nicotine products within
the last 12 months:
Yes   No
UK resident:
Domicile:
National Insurance No:
Sex:
Male   Female
Height
Weight
 
 
 
 
   
   
   
Brief outline of medical condition / occupation / past time:
For medical condition please state current or past medical treatment. Also state any investigations or operations made plus the frequency of any follow ups / check ups needed:
 


Please use the box below to tell us any further information regarding your requirements:


 

Note to accompany post code field: insurance companies often take account of post code areas when pricing annuities/life cover. While it is not compulsory to complete this field, it will help us to help you. your privacy

 

OUR UNDERSTANDING IS THAT YOUR COMPLETION OF THIS FAST TRACK ENQUIRY CONSTITUTES A LIMITED FACT FIND WITHIN THE MEANING OF THE FSMA 2000 AND ITS SUBMISSION, AN ELECTRONIC SIGNATURE. THE ADVICE THAT WE OFFER WILL BE BASED ONLY ON YOUR SPECIFIC REQUEST.