IncomeShield– Underwritten by Pinnacle Insurance plc
Income Insurance

Income insurance protects your ability to meet your financial outgoings if you are unable to work due to an accident, sickness or unemployment.

Please fill out this form below and return it tome so that I can provide you with a quote for IncomeShield.

Please note that this form is not an application form. I must discuss the policy features and benefits with you to ensure that it meets your demands and needs before submitting an application on your behalf.

Applicant Details
Title & Full Name
Address
including postcode
Date of Birth
/
DD MM YYYY / Sex / Male
Female
Employment Status / Employed / Self-employed / Fixed-term contract
Employer Name
Employer Address
including postcode
Employer Industry
Job Title
Insurance Details
Gross Monthly Income / £
Monthly benefit required (max 65% of your gross monthly income). / £
What type of cover do you require?
Accident, Sickness &
Unemployment / Accident & Sickness
Only / Unemployment Only
What Qualification period do you need for Unemployment cover(if applicable)?
30 day Back to day 1 / 60 day Excess
30 day Excess / 90 day Excess / 180 day Excess
What Qualification period do you need for Accident & Sickness cover(if applicable)?
30 day Back to day 1 / 60 day Excess
30 day Excess / 90 day Excess / 180 day Excess
What Benefit period do you need?
12 months / 24 months (only on
AS part of policy)
What date would you like your policy to start? / DD MM YYYY
Important Note: Under no circumstances can cover under this policy be backdated.
If you are currently unable to work due to a disability, insurance cover under this policy will only commence on the day you return to work.
If you wish to transfer cover from an existing policy, please provide the following information.
What is the existing type of cover? / ASU / AS / U / Other
(if other please specify)
Name of existing provider
Start date of existing policy
DD MM YYYY
Amount of monthly benefit insured on existing policy / £
Have you made a claim for unemployment within the last 3 years? / Yes / No
Note: You should not cancel existing creditor policies until you have received confirmation that your IncomeShield application has been approved.
New Borrowers
Are you applying for or have you taken a new credit agreement for a secured or unsecured loan in the 60 days before the start date of this policy? / Yes / No
If yes, please provide the date the agreement started:
DD MM YYYY
Please answer the following questions by ticking the appropriate box
Underwriting Questions
I confirm I am aged 18 or over but under 64 years / Yes / No
I confirm my work is not temporary, casual, seasonal or irregular / Yes / No
I confirm I am living in the UK, Channel Islands or Isle of Man and I am in paid employment for at least 16 hours per week with one employer? / Yes / No
I confirm I have been in employment for at least the last 12 continuous consecutive months with my current employer or if I am self employed or a fixed term contract worker for at least 24 continuous consecutive months, immediately prior to the start date of this policy / Yes / No
I confirm I have been made aware of the pre-existing medical conditions of this policy / Yes / No
Are you aware of any circumstance which may result in you making a claim under this policy? / Yes / No
I can confirm that in the last 9 months my employer has not formally announced its intention to make cuts to its workforce or made any mandatory reduction to basic salaries or contractual working hours at my location of work / Yes / No
I confirm that in the last 9 months my employer has not announced that it is going into administration, receivership or liquidation / Yes / No
I can confirm in the last 9 months I have not received any formal or informal notification that my own job might be at risk / Yes / No
I confirm that I have not been registered as unemployed at any time in the 24 months immediately prior to the start date of this policy / Yes / No
Failure to disclose all circumstances relevant to the insurance policy could invalidate any insurance cover in the event of a claim.
Once you have completed this Data Capture Form, please return this to me so I can produce an insurance quotation for you, based on your needs.
Data Protection: Please contact me if you require further information regarding how we handle and store your personal data.
Client Name
Date
DD MM YYYY