INSURANCE
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IMPORTANT: We will not do any searches with lenders before we have spoken to you first.
Insurance Cover Details
What type of cover do you require?
Please Select
Term
Mortgage Protection
Mortgage Related
None Mortgage Related
*
Benefit Type
Please Select
Death Benefit Only
Critical Illness Only
Death or Earlier Critical Illness
*
Who Is The Cover For?
Please Select
Yourself
Yourself & Partner
*
How much cover do you need?
Please Select
£20,000
£25,000
£30,000
£35,000
£40,000
£45,000
£50,000
£55,000
£60,000
£65,000
£70,000
£75,000
£80,000
£85,000
£90,000
£95,000
£100,000
£105,000
£110,000
£115,000
£120,000
£125,000
£130,000
£135,000
£140,000
£145,000
£150,000
£155,000
£160,000
£165,000
£170,000
£175,000
£180,000
£185,000
£190,000
£195,000
£200,000
£205,000
£210,000
£215,000
£220,000
£225,000
£230,000
£235,000
£240,000
£245,000
£250,000
£255,000
£260,000
£265,000
£270,000
£275,000
£280,000
£285,000
£290,000
£295,000
£300,000
£325,000
£350,000
£375,000
£400,000
£425,000
£450,000
£475,000
£500,000
£550,000
£600,000
£650,000
£700,000
£750,000
£800,000
£850,000
£900,000
£950,000
£1,000,000
*
How Long For?
Please Select
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Years *
Premium Frequency
Please Select
Monthly
Annually
*
Waiver of Premium?
Provides premium payments on your behalf, in event of long term ill health or incapacity.
Please Select
Yes
No
*
Is there any serious medical history we should be aware of:
Please Select
Yes
No
Please enter any medical history in the box below
Your Personal Details
Name
Mr
Mrs
Miss
Ms
*
Email
*
We will email your quote to this address, please make sure it's correct!
Home Telephone
*
Mobile Telephone
Work Telephone
Best Time to Contact
Please Select
Morning (9am to Noon)
Afternoon (Noon to 6pm)
Evening (6pm to 8pm)
*
Date Of Birth
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1901
1900
*
Sex
Male
Female
Smoker
Yes
No
Your Partner's Details
Name
Mr
Mrs
Miss
Ms
*
Date Of Birth
1
2
3
4
5
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30
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March
April
May
June
July
August
September
October
November
December
1984
1983
1982
1981
1980
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1972
1971
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1965
1964
1963
1962
1961
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1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
*
Sex
Male
Female
Smoker
Yes
No
By submitting this application form/mortgage enquiry I/We agree that:-The information provided is true and accurate and I/We understand that we will be contacted by a member/broker of Campion Mortgage Services.
I Agree
Please untick box if you do not wish to be contacted about other related products from our introduced companies.
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THINK CAREFULLY BEFORE SECURING OTHER DEBTS AGAINST YOUR HOME.
YOUR HOME MAY BE REPOSSESSED IF YOU DO NOT KEEP UP REPAYMENTS ON A MORTGAGE OR ANY OTHER DEBT SECURED ON IT.
Campion Mortgage Services is an Appointed Representative of Mortgage Broking Services Ltd which are
Authorised and Regulated by the Financial Services Authority, FSA No: 306012.
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