Annuity Enquiry Form

Your name

Title*

First name*

Surname*

Gender*

Male
Female

Date of birth*

Occupation

Contact details

Telephone number

Email*

Enter Email Confirm Email

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Annuity requirements

Total fund value*

Source of funds*

How much tax free cash do you require*

Please enter a number from 0% to 25%.

Please enter an amount between 0% and 25% (maximum tax free cash is 25%)

Payment frequency*

Level or increasing income*

Guarantee period*

Spouses pension

Would you like a pension paid to your spouse in the event of your death?*

Yes
No

If yes what percentage of the income from your annuity would you like paid to your spouse?

Please enter an amount between 1% and 100% (if you have chosen a spouses pension)

Your spouses date of birth

This is only needed if you have chosen to include a spouses pension

Medical details

Are you a smoker?*

Yes
No

If yes please state how many cigarettes and/or how much rolling tobacco you smoke per week

If you are a smoker please confirm how many years you have smoked for

Do you suffer from any medical conditions? (this information can help us obtain enhanced rates)*

Yes
No

If yes please give further information below

We may contact you to ask for further information. This helps us get accurate quotes.

Does your spouse have any medical conditions? (only applicable if you have chosen a spouses pension)

Yes
No

If yes please give your spouses medical information here

We may contact you to ask for further information. This helps us to get accurate quotes.