Illustration Request

You may produce personal illustrations using our online Illustration System. However, if you would like us to send you a personal illustration for your client please complete the form below.

As Income Assured Plus has an investment option you will need to be authorised by the Financial Services Authority to give investment advice to your clients on the suitability of this product.

Please refer to the Key Features brochure to make the correct selections.

If you have any questions please contact our Customer Care team on 0800 587 5098 or email customercare@cirencester-friendly.co.uk.

For more information on features of Income Assured Plus please refer to the Product Guide.

To ensure a prompt turnaround please complete all items (where applicable).

Email *

Adviser Name *

Adviser FSA Number

Company Name

Company FSA Number

Part of a Network?

Yes

No

If Yes, Network Name

Network FSA Number

Address 1

Address 2

Town/City

County

Postcode

Telephone

Fax

Client Title

Client Forename

Client Surname

Client Date of Birth

Retirement Age (select all that apply)

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

Sick Pay Benefit to be paid from (select all that apply)

Day one

1 week

4 weeks

8 weeks

13 weeks

26 weeks

52 weeks

Accident Protection (select all that apply)

Yes

No

Index Linking (select all that apply)

Yes

No

Type of Contract (select all that apply)

Protection

Protection with investment

Client Annual Salary (required to prevent over insurance)

Weekly Benefit Required (specify all that you require illustrations for separated by commas)

Disability Definition

Commission Option

If Combination or Client Bonus enter the amount of Commission you wish to take up front

How would you like to be contacted? (Please ensure you have completed the details above for your preferred method)

Email

Fax

Post