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Summary of Cover

Provider Name:

Monthly Benefit:

Waiting Period:

Quote Type:

Annual Salary:

Employment Status:

Personal Details

Policyholder Name:

Date Of Birth:

Telephone Number:




Direct Debit Details

Name of account holder(s):

Bank Name:

Sort Code:

Account Number:

Preferred Payment Day:

Policy Document(s)

Pre-existing Statement

Benefits under this policy will not be paid if inability to work is caused directly or indirectly by a pre-existing medical condition - unless symptom free and have not consulted a doctor or received treatment for the condition for at least 24 months after start date.


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