Name:

Email:

Date of Birth:

Postcode:

Account Provider Name (Bank / Building Society / Credit Company):

Account Number:

What was your employment status at the time you took out the finance?
full time employedpart time employedself employedcontractingretiredunemployeda student

If you were employed, what was your job title and the name of your employer?

Approximately how long had you been working there?

If your employment status has changed since you took out the insurance, please tell us how (e,g, if you were self employed, but are now employed)?

If you were entitled to sick pay from your employer, for how long would you have been entitled to it?
less than 3 months3 months or more, but less than 6 months6 months or more, but less than 12 months12 months or moreStatutory OnlyNot Entitled / Not Employedother (please tell us more below)

What is your current job title, and the name of your current employer?

Would you have had another way of making repayments, such as savings, if you lost your employment?
from savings or insurance; worth less than 3 months of your payfrom savings or insurance; worth 3 months or more, but less than 6 months of your payfrom savings or insurance; worth 6 months or more, but less than 12 months of your payfrom savings or insurance; worth 12 months or more of your paynoneby some other means (please tell us more below)

Were you asked about your medical history?
yesnodon't know

Did you have any pre-existing medical conditions?
yes (please tell us more below)nodon't know