This helps us to check that you're eligible and work out your cover amount and premium.

Title
First name

If you have more than one first name, use a hyphen between them. For example, ‘Sarah-Jane’. You don’t need to tell us your middle names.

Last name
Your gender
Your date of birth (DD/MM/YYYY)

This helps us to check that you're eligible and work out your cover amount and premium.

Smoking, vaping, tobacco and nicotine use

We need accurate information about your use of cigarettes, cigars, a pipe or any other tobacco or nicotine products including nicotine gums, patches, inhalers, tablets, lozenges, sprays and electronic products, even if only on an occasional basis. It’s an important factor in our assessment of terms and payment of claims.

Email address

Please give us your preferred email address. We’ll use this to send you your quote and we may use this to contact you to progress your application.

Mobile or phone number (optional)

Please give us your preferred phone number. We may use this to contact you to progress your quote or application.

Postcode

To apply you must be in the UK, have a legal right to live in the UK and consider your main home as being in the UK, with no current intention of moving anywhere else permanently.

The UK does not include the Channel Islands, the Isle of Man or Gibraltar.

If you’re moving home, use your current address. You can change this after you have moved.

Keeping you informed

From time to time, we’d like to send you offers and discounts we think you’d be interested in.

Tell us if you don’t want to hear from us.

How we keep you informed

If you would prefer not to receive communications about our products and promotions, please indicate below. You can always tell us if you change your mind.