Income and mortgage payment protection application form

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Please use the form below to request proposal forms for mortgage and income protection. - or telephone 0870 7456247


Your name
E-mail address
Address line 1
Address line 2
City
County
Post code
Age
Telephone No.

Gross Income	(monthly before tax - you can average any bonuses/ overtime)
Total Benefit	i.e. total cover wanted
Mortgage payments
Other monthly bills	(utilities, loans, credit cards, insurance, school fees etc)
Policy wanted	Benefit period Excess NB - remember that the first qualifying day would be after any notice period ends. We do not recommend long excess period. Benefits NB If you choose unemployment only, be sure that you have adequate disability insurance NOT employer related as you would lose the benefits if you lose your job.
Comments contract, details etc
Have you any specific demands and needs?	I have no specific demands and needs
Declaration I have completed the form to the best of my knowledge and belief. I have made a full disclosure of all material facts. I have read and understood the Important information below. I understand that there is no cover in force until confirmed by B. Portwood & Co Ltd, a satisfactory proposal form completed and accepted and payment of the premium made - either in full or an instalment plan set up acceptable to B. Portwood & Co Ltd.

Note: Hit submit button once only

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Our main website has information on landlords insurance - it is found here and another page is about buy to let insurance found here.