Illustration request for a Lifelong Protection Plan - Critical Illness Benefit

Please enter the following details to enable us to provide your individual illustration which will be returned to you by post:

	Personal Details
	*Date of Birth	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ( Minimum age 16, maximum age 70.)
	Sex	Male Female

	Product Details
	Please insert a value in one or other of the following questions.
	Sum assured	£ (minimum £1,000)
	Premium Amount	£ (minimum £10 per month or £100 per annum)
	Premium Frequency	Monthly Annually

How long would you like this cover to continue? ( Please enter either the number of years you would like the cover to continue or the age at which you would like it to stop).

	Years	(minimum 5 years)
	Age	(maximum age 70)

	Would you like the additional benefit of waiver of premium? Yes No
	After six months incapacity, we don't require you to pay your premiums for the duration of the incapacity. This benefit ceases at age 60.

Would you like to insure a second life on the same policy? Yes No

	(Payment would be made on the event of the first death) If so, please enter their personal details:
	Title	Mr Mrs Ms Miss Other Other
	Surname
	Forename(s)
	Date of Birth	Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec ( Minimum age 16, maximum age 70.)
	Sex	Male Female

Please enter the correspondence address to which you would like the illustration sent:

	Title	Mr Mrs Ms Miss Other Other
	*Surname
	*Forename(s)
	*Address
	*Postcode
	Daytime Telephone Number
	*Email address
	If you already have a policy with Windsor Life, please enter your policy number(s) here:
	Policy number(s)

Data Protection Act 1998 The information which you provide on this form along with other information relating to you will be held by Windsor Life Assurance Company Ltd and used for general business purposes and, in particular, to provide the information you have requested. Details about you and your request may be passed to companies with which we have a business relationship, to confirm update and enhance their customer records, and to advise you (by post, telephone, or other electronic media) of any products and services that may interest you. If you do not wish to receive marketing information, please tick this box.