Apply online

If you would like to apply online please complete the following application form and click submit. Your application will then be submitted for underwriting, if accepted you will be issued with a policy by the administrator (Paymentshield).
Full Name 1st Applicant:
Date of Birth:
Address of mortgaged property: If correspondence address different put details in additional info.
Tel No Home:
Employment status
Occupation:
Name of Employer:
Full Name 2nd Applicant:
Date of Birth:
Employment status
Occupation:
Name of Employer:
Cover / Split  Single cover       Joint cover         cover
 

You

Your Partner
Are you actively working in the United Kingdom, Channel Islands or Isle of Man for at least 16 hours per week? yes No Yes No
 
Is your work temporary, casual or seasonal (including any work for a employment agency)?. yes No Yes No
 
Have you at any time in the last 12 months been registered as unemployed? yes No Yes No
 
Do you know about any circumstances which may result in you becoming unemployed? yes No Yes No
 
Are you in dispute or in the course of any disciplinary action which may result in you becoming unemployed? yes No Yes No
 
Have you consulted a doctor (or consultant) in the last 12 months? yes    No Yes No
 
Do you know about any circumstances which may result in you becoming disabled? yes No Yes No
 

Important note- if you have ticked any of the shaded boxes, please give us more information in the additional information section.

What type of cover do you need?    Unemployment & disability  Unemployment only  Disability only
 
What excess period do you need?   30 days 60 days
 
Enter the amount of cover you require £
Enter monthly premium (from premium calculator) £
 
What is the name of your mortgage lender?
Mortgage start date
Policy start date
Bank Details
Names of account holder (s)     
Bank / Building society account number 
Branch sort code  
Name and full postal address of your bank / Building society
 
Payment date: I wish to pay monthly on: or just after
 
Additional Information