Applicant
Title (Mr, Mrs, etc.)
First Name
Surname
Sex Male   Female
Date of birth
Occupation
Contact Details
Telephone Number DAY  EVENING
Email Address
House Name or Number
Address
 
 
Town
County
Postcode
Annuity Requirements
Amount to be Invested £'s Sterling  
Source of Funds Tax Free Cash from Pensions
If your source of funds is Protected Rights how much of the fund is Pre 97 Post 97 £'s Sterling
Start Date (approximately)  
Tax Free Cash of % Tax Free Cash from Pensions
Type of Annuity Different Types of Annuities
My Income Payments are  
Escalation Required Increase Your Pension in Retirement?
Guaranteed Payment Period Required No Guarantee  5 Years       10 Years Guaranteed Annuity Payment Period
Do you smoke tobacco products? (ignore cigars)      NO       YES
If yes please state your level of consumption
Number of cigarettes each day with brand names.
Ounces of tobacco each week (Roll ups and pipes)

Other Requirements
Pension for Spouse NO                YES  
If yes , how much? % of the full pension A Pension for Your Spouse?
Spouse's date of birth  
Does your spouse smoke tobacco products 
(ignore cigars)		 NO       YES  
If yes please state level of consumption
Number of cigarettes each day with brand names.
Ounces of tobacco each week (Roll ups and pipes)

Do you or your spouse suffer from any medical condition that might effect your life span?

SELF

SPOUSE

YES       NO

YES       NO

If yes please give full details

SELF

SPOUSE

Would you like us to telephone you and discuss your requirements before we produce your report? NO   YES
Please confirm that you have read our Terms of Business.  

 
        

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