Untitled Document

Accident Sickness Unemployment Cover

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1st Applicants Details

1st and 2nd Applicants Employment status: customer who are proprietors or shareholding directors who own 20% or more of the issued shares of the business that they work for, will be classed as self-employed. Also customers who are related to a Proprieter or shareholding director of the business thay work for will also be classed as self-employed.

Title

Initial

Surname

DOB

Empolyment Status

Employed

Self Employed

Shareholding Director

Proprietor

2nd Applicants details (if applicable)

Title

Initial

Surname

DOB

Empolyment Status

Employed

Self Employed

Shareholding Director

Proprietor

New Borrowing (mortgage is less than 30 days old)

All new borrowers will recieve between 3 and 6 months initial free periods.

Existing borrowers will recieve 3 months free cover from the policy start date.

Are you a new borrower?

Claim Period

If you require a 24month claim period, Please indicate below. Benefit of up to £2500 per month can be selected for 24 month covers.

12months

24months

Type of Cover

Disability & Unemployment

Unemployment Only

Disability Only

Qualification Period

30 Day Back to Day One examples: On the 31st day of continuous unemployment or disability, we pay an amount equal to one monthly benefit. From the 31st day onwards will pay 1/30th of the monthly benefit for each day you remain continuously unemployed or disabled. Any claim benefits due to you will be paid monthly in arrears.

30 Day Excess examples: From the 31st day onwards we will pay 1/30th of the monthly benefit for each day you will remain continuously unemployed or disabled. Any claim benefits due to you will be paid monthly in arrears and the first payment will be made on the 61st day back dated for 30 days. This means you will recieve no benefit for the first 30 days which is known as the excess.

Qualification type:	Back to Day one		Excess Period
Qualification period:	30 days		60 days

Cover Breakdown

The maximum total monthly benefits limit including the 25% additional benefit is £1500 or an amount equal to 75% of your normal income whichever is the lower.
On our FreeStart policy the 25% extra benefits is offered as additional cover free of charge.

Monthly Mortgage Payment

Other Mortgage/Life/Household Related Insurance

Total Monthly Benefit

25% Extra Cover Required?

Mortgage Details

Mortgage Completeion Date

Mortgage
Lender

Policy Start Date

Eligibility Questions

	1st Applicant		2nd Applicant
1. Are you actively working in the United Kingdom, Channel Islands or Isle of Man for at least 16 hours a week?	Yes	No	Yes	No
2. Is your work temporary, casual or seasonal (including any work for a temporary employment agency)	Yes	No	Yes	No
3. Have you at any time in the past 12 months been registared as unemployed?	Yes	No	Yes	No
4. Do you know of any circumstances which may result in you becoming unemployed?	Yes	No	Yes	No
5. Are in dispute or in the course or any disciplinlinary action with your employer (including and performance-related-issues)?	Yes	No	Yes	No
6. Have you consulted a doctor (or consultant) inthe past 12 months?	Yes	No	Yes	No
7. Are you named on the Mortgage Application?	Yes	No	Yes	No
By submitting this enquiry I/We agree that:-The information provided is true and accurate and I/We understand that we will be contacted by a member/broker of First Rate Mortgage Services.
I Agree

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