Lifestyle Information Capture : The Source

When completing the Information Capture Form, or having your Insurance Advisor complete it on your behalf, you must provide all material facts. Failure to disclose such necessary information or disclose false information could invalidate any insurance cover in the event of a claim. Note to the Introducer: The Information Capture Sheet is provided for the purposes of capturing client’s cover requirements prior to producing a full quotation using the Source software. Submission to underwriters of an Information Capture Sheet is not an acceptable means of application. A fully completed Application Form produced from the Quotation Documentation section of the software and submitted electronically is the only acceptable means of submitting new business to underwriters for acceptance.

Applicant Details

Title
Forenames

Surname
Date of birth

Mobile phone number
Telephone number

Email address

These policies offer electronic documents as standard. If you would prefer hard copies of your documents posted, please tick the box.

Are you a permanent resident of the UK? Yes No

Have you been residing in the UK continuously for the last 6 months? Yes No

Do you smoke? No, never smoked Yes, current smoker Ex-smoker

Have you received treatment or medication for a medical condition in the last 12 months? Yes No

Are you awaiting referral or consultation for any condition or are you off work at the time of completing this application? Yes No

Do you have an existing Lifestyle policy? Yes No

Would you like to apply to transfer cover from an existing scheme? Yes No

Have you made a claim within the last 24 months? Yes No

Are you aware of any redundancies, restructure, reorganisation, financial or contractual threats within the business you work in, even if you do not believe these actions will result in you becoming unemployed? Yes No

Cover Details

What do you want to cover? Income Rent Mortgage

Monthly cover amount

What is your gross annual income?

Cover required Accident & Sickness only Unemployment only Accident, Sickness & Unemployment

Benefit period? 6 Months 12 Months 18 Months 24 Months

Cover Commencement Date

When would you like the cover to commence?

The Property

Insured (risk) Address

Address line 1
Address line 2

Address line 3
Address line 4

Postcode

Is the correspondence address the same as the insured address? Yes No

Employment

How many hours a week do you work? Less than 16 hours More than 16 hours

What is your occupation?

What is your nature of business?

Employer's Name

Nature of Business Employed Self-Employed Contract Worker

How long have you been in continuous work? A) 12 months or more B) Between 6 and 12 months C) Less than 6 months

Have you been working in the UK continuously for the last 6 months? Yes No

Are you currently in work? Yes No

Is your work temporary, casual or seasonal (including any work for a temporary employment agency)? Yes No

Notes

By submitting this form, I confirm that the information given in this form is true, complete and accurate to the best of my knowledge.

Lifestyle Insurance - Information Capture Form

Applicant Details

Cover Details

Cover Commencement Date

The Property

Employment