Please read these important notes carefully when filling out this form.

  • Please answer the questions as accurately as possible.
  • We can only provide your Quotation on the basis that you are in Good Health. If this is not the case, then please contact our office on 0208 207 7394 to discuss your situation.
  • Tell us about the Type of Cover that you want. Enter a figure for the term (the period for which insurance is required) in whole years, and the amount of cover needed (in Pounds Sterling £). We currently provide quotations for protection insurance.
  • Press the Submit button - our adviser will get back to you shortly with your quotes.
  • Please note that this offer does not represent personalised advice and is not a recommendation that this product, level of cover or provider selected matches your financial requirement. If you should have any doubts about whether this product meets your own needs, please contact us so that your individual circumstances can be considered.


Income Protection Questionnaire

What other elements within your cover are you looking for






Are you



Further details of terminology with long term insurance can be found here.  We will always quote including both Waiver of Premium and Indexation benefit where appropriate.

We may share your details with associates who can give advice about your cover and review your circumstances.  Our objective is to save you money without compromising your cover or changing your cover to suit your needs.

  • Waiver of premium means we’ll waive your premiums, if you can’t work due to incapacity, caused by an illness or accident.
  • Insurers may have different definitions on the waiver and how it works.  Speak to us to find out more.
  • The indexation option - with this option the client can help ensure their cover keeps pace with inflation. It allows the plan to keep pace with inflation by increasing the amount of cover in line with the Retail Prices Index (RPI) - but can also be chosen based on the (Average Earnings Index) AEI as well, each year. This can be done without the need for any further medical evidence. It can be chosen with Level Term Assurance, Critical Illness Cover Plans, all Family and Personal Income Plans, Income Protection Benefit Plan and Whole of Life Protection Plan.
  • Premiums will be quoted monthly.

This form gives us the initial information we need to start a quoting process, however it may differ greatly to what your requirements actually are.  Speak to us about any uncertainties, and we will advise on the level of cover you may need.

Proactive Medical & Life Ltd Registration Number: 06483379 is an Appointed Representative of Healthnet Services Limited, who are authorised and regulated by the Financial Conduct Authority. Healthnet Services Limited entered on the FCA register No 312313