There are many reasons individuals may find it difficult to obtain life assurance. The most common are people who have a medical problem such as a heart condition, mental health condition or any condition which requires daily medication. It is also hard to get life assurance if you have a hazardous occupation or work abroad. Together with our insurers, we assess all cases on an individual basis to provide the best terms available.

Please complete the form below and one of our dedicated team will call you back within 24 hours.

Proposer Information


E-Mail Address*

Contact Tel No*




Smoker Status*

Policy Information

Type of Policy*

Single or Joint*

Number of years*

Medical Information

Proposer 1

Name of medical condition*

Date of diagnosis*

Details of hospital treatment*

Additional conditions

Proposer 2

Name of medical condition (Proposer 2)

Date of diagnosis (Proposer 2)

Details of hospital treatment (Proposer 2)

Additional conditions (Proposer 2)
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