Prepared For
Gender
Smoker :
ANB / DOB* :
Lump Sum on Death Sum Assured :
Serious Illness Sum Assured :
Monthly Income on Death Sum Assured :
Term of Cover for Income on Death :
Whole of Life Sum Assured* :
Hospital Payment :
Accident Payment:
Broken Bones Payment :
Surgery Payment :
Term of Cover for Lump Sum Benefits :
Mortgage Interest Rate : (only relevant for mortgage protection)
Premium Frequency :
Indexed :
Basis :
Covers :
Type :
in association with                



* WOL Continuation Sum Assured. This benefit provides life cover of the selected amount on a whole of life basis. No premiums are payable after the term, but the cover continues.