Please use the form below to request independent financial advice. The form is detailed and asks many questions. -or contact
Jennifer Morris M.A., MLIA (dip) on 0191 4952395

Your Details
	Mr Mrs Miss Ms First Names Surname d.o.birth
	Good Health Moderate Health Poor Health Smoker Non Smoker Single Married Commmon Law Seperated Divorced Widowed Retired Employee Self Employed Unemployed Made Will Not yet
E-mail address
Partner's details	Mr Mrs Miss Ms First names Surname d.o. birth
	Good Health Moderate Health Poor Health Smoker Non Smoker Single Married Commmon Law Seperated Divorced Widowed Retired Employee Self Employed Unemployed Made Will Not yet
Address	:Postcode
Telephone No.
Dependants (inc grandchildren)	Name : d.o.b Male Female Single Married C.Law Child Grandchild Parent In-Law Other Name : d.o.b Male Female Single Married C.Law Child Grandchild Parent In-Law Other Name : d.o.b Male Female Single Married C.Law Child Grandchild Parent In-Law Other Name : d.o.b Male Female Single Married C.Law Child Grandchild Parent In-Law Other
My Occupation	Employed Self Employed Retired Other Monthly: Salary Investment/Pension income
Partner occupation	Employed Self Employed Retired Other Monthly: Salary Investment/Pension income
Assets	Myself Partner
House(s) Possessions Stocks/Shares Liquid Assets PEPs Partnership Any Other Assets
Liabilities	Mortgage : Type endowment Repayment Pension PEP Repayment date ASU cover? Select No Yes Mortage is single Basis Jojnt Basis Paid on death Not paid on death
Fixed Expenditure (Monthly)	Mortgage Rent Other property loans HP Loans Other loans Maintenance Regular insurance premiums Other insruance premiums health Insurance premiums Pension contributions Investment Premiums Other regular savings Community Charge Water Rates Educational fees
Variable Expenditure (Monthly)	Food Telephone Gas/ electricity Other Fuels Motor expenses Clothing/ Personal Care Entertainment Travel Holidays Gifts/ donations Miscellaneous
Priorities	(Grade 1 to 5 - 1 being most important, 5 being least important)
	Paying off your mortgage Family protection - life assurance Critical Illness cover Family protection income if unable to work Retirement planning Increase savings Raising immediate finance Inheritance tax planning Education fees planning Medical care Being able to afford practical help in old age
LIFE ASSURANCE	If I die my partner would need : p.a. If my partner dies I would need p.a. If I die my partner would receive If my partner dies I would receive I hold private health insurance I do not have private health insurance My partner is covered My partner is not covered Will you have an income in the event of disability Select No Yes Will you receive a lump sum on diagnosis of a serious illness Select No Yes
SAVINGS	Regular Savings and Investments inc Bank/B.Soc a/c, Invetment bonds, Unit Trusts, PEPS
	Type of Investment Self- regular amount Self - Value Partner - Regular amount Partner Value
PENSIONS
A - Employed	Myself My Partner At what age do you expect to retire Retirement Income required if it was today Are you contracted out of Serps? Are you in a company pension scheme Will you be eligible to to join If so when?
B - Self Employed	At what age do you expect to retire Retirement Income required if it was today What is your most recent profit declared
C - Both	Who Type of scheme Begun? Comapny Cotributions Benefits Life cover
	Do you have any preserved pensions None Myself My partner Both of us Details
I understand that this information will be used solely for an initial assessment and that further information may be required.
Other information - Assets, Liabilities, future plans etc.
RISK - generally	I am very cautious and do not want any unnecessary risks I am relatively cautious but don't mind a small risk I am fairly conservative but will accept a reasonable risk I am quite adventurous and can accept a greater level of risk I am quite speculative about money
RISK - pension funds	I am very cautious and do not want any unnecessary risks I am relatively cautious but don't mind a small risk I am fairly conservative but will accept a reasonable risk I am quite adventurous and can accept a greater level of risk I am quite speculative about money
	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

Links to lists of our other main policies

B Portwood & Company Insurance Home Page - an overview of the site and types of policy on offer.
Financial and medical insurance - accident and sickness insurance, private medical health insurance, life, critical illness, mortgages