Illustration request for an Investment and Protection Plan (Regular Savings Plan)

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

	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 18, maximum age 75 at maturity)
	Sex	Male Female

	Product Details
:	Please enter Benefit Amount or Premium Amount
	Benefit Amount (in £s)
	Premium Amount (in £s)	(Minimum £10 per month or £100 per annum)
	Premium Frequency	Monthly Yearly
	Policy Term	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 years
	Would you like to include waiver of premium benefit?		Yes No
	Would you like to insure another life on the same policy? payment would be made on the event of the first death)		Yes No

	If you would, 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 18, maximum age 75 at maturity)
	Sex	Male Female

	You can distribute your investment between the following funds:
	Please enter the percentage splits you require
	American	%
	Balanced	%
	Deposit	%
	European	%
	Far East (including Japan)	%
	UK Fixed Interest	%
	Index Linked	%
	International	%
	Japan	%
	Managed	%
	Property	%
	Special Situations	%
	Tracker	%
	UK Equity	%
	Total	%

	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.