Your Details
Single or Joint?

	1st Applicant	2nd Applicant
Name
Sex
Date of Birth (dd/mm/yyyy)	/ /	/ /
Are you a smoker?

Contact Phone No.
Email Address


Product Options
Product Type
Benefit Type (Critical Illness quotes are based on Class 1 Occupation.)
Premium Frequency
Term in Years

Premium I wish to Pay		£
OR
Amount of Cover I want		£

Increasing Benefit? (Not available for Mortgage protection)
Waiver of Premium? (Based on 26 weeks deferment period)


I agree that Pacific Financial Services ( North West ) may use my data in accordance with their Data Protection Statement.
I agree that Pacific Financial Services (North West) or any company associated with them may contact me for marketing purposes by e-mail, telephone, post or SMS.

Your home may be repossessed if you do not keep up repayments on your mortgage. The Financial Services Authority does not regulate certain aspects of Buy to let mortgages.

Pacific Financial Services (North West) 150 Briercliffe Rd Burnley Lancs. BB10 2NZ is authorized and regulated by and regulated by the Financial Services Authority We are entered on the FSA register No 302245 at www.fsa.gov.uk/register. There may be a fee for mortgage advice, the precise amount will depend on your circumstances but we estimate that it will be £195. The guidance and/or advice contained within the website is subject to the UK regulatory regime and is therefore primarily targeted at customers in the UK.

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