Whole of Life Application Form (W10243) - Legal & General

SECTION A QuoteInitial Client detailsFull name and titlePlease ensure you giveall of your middle names.Client oneMr/Mrs/Miss/Ms/Dr/Rev/OtherForename(s) and middle name(s) in fullClient twoMr/Mrs/Miss/Ms/Dr/Rev/OtherForename(s) and middle name(s) in fullSurnameSurnameGenderMaleFemaleMaleFemaleDate of birthD D M M Y Y Y YD D M M Y Y Y YHave you used cigarettes, cigars,pipes, or nicotine replacementsin the last 12 months – includingoccasional use?Yes NoYes NoA simple medical test may be required to check the validity of the answer to this question.Employment statusFull timeemployeeSelfemployedPart timeemployeeRetiredContractworkerStudentFull timeemployeeSelfemployedPart timeemployeeRetiredContractworkerStudentUnemployedHousepersonUnemployedHousepersonAbout your planClient one Client two JointWhat amount of cover do you want?orWhat is the premium amount?££ £OROR£ £ £ORIs this policy for:Family ProtectionInheritance Tax planningBusiness ProtectionIf this policy is for BusinessProtection, do you require the sumassured to be paid in instalments?Yes No Yes No Yes NoIf ‘Yes’, please select benefit payment option required:2 years3 years5 years2 years3 years5 years2 years3 years5 yearsPage 4Whole of Life Protection Plan – Application Form and Additional Questionnaires