Critical Illness Cover Quote

Thank you for your interest in our Critical Illness Cover. Please complete as many of these fields as you can so we can prepare an accurate quotation that fully reflects your needs. We’ll arrange a telephone consultation to discuss your requirements in more detail.

Your Details


Title
First Name *
Surname *
Date of Birth *
Have you smoked in the last 12 months? *
Marital status

Address and contact details


First line of address
Town
Postcode *
Telephone Number *
Email *

Employment


Employment status *
Age expected to retire *

Cover


Do you have existing cover?
If Yes, who is your existing cover with?
Year it was taken out
Amount of cover
Term of cover
Premium
Outstanding mortgage balance?
How did you hear about us? *
Please specify what MIAB can contact you about in the future:


How can we contact you regarding this: