Step 1 of 5 20% About youWhat's your title*MrMrsMissMsName* First Last What's your marital status?*MarriedSingleCommon lawSeparatedDivorcedWidowedYour date of birth:* DD MM YYYY What's your postcode?*Are you a smoker?*(Have you smoked or used nicotine products (patches, e-cigarettes etc.) in the past 12 months?)YesNo About your coverHow much cover do you need?(Leave blank if you're not sure yet)How long do you need your policy to last?(Leave blank if you're not sure yet)Which type of life insurance do you require?*Whole of life insuranceLevel term life insuranceDecreasing term life insuranceNot sure About your lifestyleHow tall are you?*(In feet and inches)How much do you weigh?*(In stones and pounds)What is your job title?*Which of the following options best describes you?*I have never smokedI used to smoke but stopped over a year agoI have smoked in the past year but not every dayI have vaped or used e-cigarettes in the last yearI have used other nicotine replacement products in the last yearHave your birth parents, brothers, or sisters had any of these before they were 65?*Heart attack, angina or strokeCardiomyopathyDiabetesBowel cancer or bowel polypsAny other cancerMuscular dystrophy, Huntington's disease or motor neurone diseaseMultiple sclerosis, Parkinson's disease or Alzheimer's diseasePolycystic kidney diseaseI don't knowNoHow many pints of beer, lager or cider do you drink per week on average?*How many glasses of wine do you drink per week on average?*How many measures of spirits do you drink per week on average?*Are you involved in any of these activities?*Armed Forces (including reserves)Scuba divingPrivate flying, gliding or parachutingMotor sportsMountaineering or rock climbingSailing at sea or powerboat racingNoDo any of these apply to you?*I have been banned from driving in the last 5 yearsI have been convicted of dangerous or careless driving in the last 5 yearsI ride a motorbike, moped or scooter on public roadsNoHave you lived, worked or travelled outside the UK or European Union in the last 5 years, or do you have any plans to do so in the next year?*YesNoDo you have any existing life insurance policies?*YesNoDo you have any existing Critical Illness insurance policies?*YesNo About your healthHave you ever had any of the following?*CancerCancer-in-situ, leukaemia, Hodgkin's disease or any other tumourHeart attack, irregular heart beat, cardiomyopathy, valve disorder or any other heart condition or heart surgeryA stroke, TIA, brain haemorrhage or damage or surgery to your brainNoHave you ever had any of the following?*Multiple sclerosis, epilepsy, Parkinson's or any other disorder of the brain or nervous systemAny mental health issue that has required a hospital or psychiatric referralA positive test, or are you awaiting the results of a test, for HIV, AIDS or hepatitis B or CNoIn the last 5 years have you had any of these?*Raised blood pressure, cholesterol or chest painDiabetes or raised blood sugarDepression, anxiety, stress, eating disorder or any other mental health issueAnaemia, blood clot or anything else affecting your bloodA growth, lump or cystNoIn the last 5 years have you had any of these?*Asthma, sleep apnoea or anything else affecting your lungs or breathingCrohn's, colitis, IBS or anything else affecting your stomach, bowel or digestive systemKidney stones, urinary infection or anything else affecting your kidneys, prostate, bladder or urineAnything affecting your liver or pancreasNoIn the last 5 years have you had any of these?*Back pain, sciatica, whiplash or anything else affecting your back or neckArthritis, gout or anything else affecting your bones, joints, ligaments, tendons or musclesNumbness, pins and needles, muscle weakness, tremor or difficulty with co-ordinationNoIn the last 5 years have you had any of these?*Tinnitus, labyrinthitis or anything else affecting your ears, hearing or balanceImpaired, blurred or double vision, optic neuritis or anything else affecting your eyesChronic fatigue syndrome, ME, fibromyalgia or persistent tirednessNoHave any of these applied to you in the last 3 years? You don't need to include things you've already told us about*I've taken or been prescribed treatment for 4 weeks or moreI've been asked to attend a follow-up or regular reviews with a GP, hospital or clinicI've been advised to see a specialist or to have any tests, scans, investigations or counsellingNoHave you had any of these in the last 3 months, even if you haven't seen a doctor?*Any lump, growth or hardening affecting either testicleBleeding from the bowel or a change in bowel habitsA cough lasting more than 3 weeksA fit or seizureA mole or skin blemish that has changed in appearanceNo Your contact detailsPhone*Our life insurance advisors will ring to provide free advice and take you through your life insurance options - look out for their phone call from the number: 01792 312078Email* This iframe contains the logic required to handle Ajax powered Gravity Forms.