Telephone No.
Email Address
Postal Address	Full postal address inc. postal code
Type of Cover Required:	Single Life Only Joint Life Cover

	First Life	Second Life
Full Name
Date of Birth
Occupation
Smoker?	Yes - I smoke No - I do not smoke	Yes - I smoke No - I do not smoke
Benefit Requirements:	Critical Illness Cover Only Critical Illness and Life Cover
	First Life	Second Life
Critical Illness Amount:
Death Benefit Amount:
Term Required:	in years
Term Type:	Level Increasing Decreasing
Waiver of Premium:
Additional Comments	Additional Information / Comments:

= Required

Unemployment Insurance can be added to this cover for a small additional premium, ask your adviser for details...

Term (Critical Illness and/or Life Cover) will require a completed application form and possibly a GP Medical Report (at no cost to yourself); dependant upon the results, your premium may be adjusted.