Income protection insurance, loan payment protection insurance and mortgage protection insurance contact form


As well as Unemployment insurance, ask us about:	Car Insurance	House Insurance	Caravan Insurance	Pet cat, dog and horse Insurance	Boat Insurance	Protection Insurance	Travel Insurance	Expert Help Included

Please provide contact details below so that we can discuss your mortgage protection insurance and income protection insurance requirements - or call us on 0870 7456247. We regret we are unable to accept on-line applications for these products. Although basic information about the contracts has been given, we will make a recommendation after we have assessed your requirements.

Income protection insurance \| Mortgage protection insurance \| Accident sickness unemployment insurance
Your name
E-mail address
Address line 1
Address line 2
City
County
Post code
Age
Telephone No.
I am interested in:	Please fill in the details below.
Gross Income	(monthly before tax - you can average any bonuses/ overtime)
Total Benefit	i.e. total cover wanted
Mortgage payments	: related payments
Mortgage Start	Date that you took out or remortgaged (if applicable)
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 unless you have resources to cover the period during which you would not be paid. 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. Unemployment cover is only available on the Delta Contract.
Comments contract, details etc, recent employment history, any medical conditions or knowledge/ suspicion that your employer is experiencing trading difficulties or is the target of a takeover.
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

This form will generate a request to us and supply an 'initial disclosure document' to your e-mail address. We will only use the information contained for the purposes of sending you information about your requested income/ mortgage protection insurance policy

Alpha Mortgage Protection Quote ( Extra Benefits)
Delta Income Protection Quote (ASU only)
Beta Mortgage payment Protection Quote (AS or ASU - no additional benefits)