Client Referral

Please complete the form below and we can start working on your referral we will then contact you with details of the cover we can provide


 Company Information

Company Information

Name of firm:
Office telephone number:
Name of advisor dealing with this case:
Advisor telephone number:Email address:
Please confirm the following:Deal directly with the client or only via the advisor:

Client Information

Client's name:
Client's telephone number:Best time to call:
Client's address:
Alternative telephone no(s):Email:
Confirmation that the client is expecting our call:  
Client's doctor:Doctor's tel:
Doctor's address:
Is the policy single life or joint:

Insurance Companies

Please list the companies that you or the client have already approached in respect of this case.
This is important to avoid unnecessary delays.

No companies approached as yet

Any Additional Information

Please provide any further information which you think may be useful:

 Applicant #1

Personal Information

Name:Sex: Date of Birth: / /
Height: Weight:
Tobacco/nicotine products used in the last 12 months (if yes, detail):
Alcohol consumption (if yes, detail with units per week):
Any employment related risk (if yes, detail):
Any leisure/sports risk (if yes, detail):

Policy Information

Policy type:Term:
Sum assured (£):Guaranteed/Reviewable:

Medical Condition and History

Medical condition:
Date of diagnosis:Date treatment ended:
Relevant readings:
Treatment given:
(surgery, medication, etc.)
Detail any further
relevant information:
Within the last 5 years have you been exposed to, or tested positive for, any of the following?
Risk of HIV infection Drug abuse HIV Positive Hepatitis B/C None
Are you waiting for the results of any such test (if yes, detail):
Have you lived or travelled outside Europe/North America/Australia/New Zealand in the past 5 years for more than 30 days or plan to do so (if yes, detail):

Family History

Have any of your natural parents, brothers or sisters, before the age of 60, been diagnosed with or died from any of the following conditions?
Father Mother Brother Sister
Age when diagnosed or died:
Heart Attack Cardiomyopathy Motor Neurone Disease Angina
Multiple Sclerosis Huntingdon's Disease Stroke Myotonic (muscular) Dsytrophy
Parkinson's Disease Poliposis coli (Familial adenotamous) Alzheimer's Disease Polycystic Kidney Disease
Any other hereditary disorder None
Cancer (detail site etc.)
Diabetes (detail type 1 or 2)
The conditions shown above are not alway hereditary and it is not intended to imply that they are.


Life Cover For All LLP (Registered in England under company Reg No OC359631) is an Appointed Representative of
Access Wealth Management, The Beacon, Beaufront Park, Anick Road, Hexham, Northumberland, NE46 4TU
which is authorised and regulated by the Financial Conduct Authority

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