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Enquiry Form

    1.PERSONAL DETAILS

    Title
    First name
    Surname
    Gender
    Date of birth
    Nationality
    Smoker
    Civil status
    Present address
    Town/City
    Address county
    Home telephone
    Work telephone
    Mobile telephone
    E-mail address
    Contact preferences

    2.DEPENDANTS

    Client Name Date Of Birth Age

    3.EMPLOYMENT AND INCOME

    Tax status
    Employment sector
    Occupation
    Employer
    Employer address
    Employment benefits :
    Death in service benefits
    Employer's income protection amount (p.a)
    Deferred period
    Private health insurance details (Brief summary)
    Income :
    Gross basic salary
    Self employed taxable income
    Pension(s)(ARF,Private etc.)
    Dividends
    Investments (excl. Net Deposit Interest)
    Deposit interest (after DIRT):
    Other taxable income (include bonus, commission, overtime etc..):
    Non taxable income (include maintenance etc):
    Monthly State benefits :
    Monthly social welfare benefits (Unemployment, illness etc)
    Mortgage interest supplement
    Monthly child benefit
    Family income support

    4.FINANCIAL COMMITMENTS

    Do you have any financial commitments? (other than mortgages)
    Client Commitment type Provider Present balance Monthly payment End date

    5.PROPERTIES AND MORTGAGE

    Do you own properties? (with mortgage)
    Client Lending institution Market value Current loan balance Current monthly repayment Property address End date Mortgage protection is in place Acc. serious illness in place Net monthly rent

    6.OTHER ASSETS

    Do you have other assets? (Including properties without mortgage)
    Client Asset Type Ref/Address Current Asset Value Original Value Asset Details Net Monthly Income Date of Purchase Split Asset

    7.PROTECTION PLANS

    Do you have any protection plans? (other than mortgage protection)
    Client Policy number Product type Provider End date Premium Frequency Value Life cover Serious IllnessCover Income protection (p.a)

    8.PENSION PLANS

    Do you have any pension plans?
    Client Policy number Product type Provider End date Premium Frequency Value Employer's premium (p.m) Employee's premium (p.m)

    9.INVESTMENT AND SAVINGS

    Do you have any investment or savings?
    Client Institution Type Account / Reference number Date account opened Current balance / value

    10.OTHER INSURANCE

    Do you have any other insurance?
    Client Type of insurance Provider Renewal date Premium p.a. Frequency Details Cover details

    Building:

    Contents:

    All risks:

    Building:

    Contents:

    All risks:

    Building:

    Contents:

    All risks:

    Building:

    Contents:

    All risks:

    Building:

    Contents:

    All risks:

    11.MONTHLY HOUSEHOLD EXPENDITURE

    Utilities
    Household
    Transport
    Primary residence mortgage related costs
    Education
    Medical
    Social / Entertainment
    Other insurances & savings
    Other

    12.Client Notice


    1) Please be aware that when completing proposals customers are required to disclose; medical details or history
    of previous insurance claims made for the type of insurance sought.


    i) a policy may be cancelled.

    ii) claims may not be paid.

    iii) difficulties may be encountered in trying to purchase insurance elsewhere.

    iv) in the case of property insurance, failure to have property insurance in place could lead to a breach of the
    terms and conditions attaching to any loan secured on that property.

    2) Where clients are represented by an introducer (accountant, solicitor, estate agent or other party) please be
    aware that information such as amount of finance approved and the amount drawn-down can be shared with the
    introducer for the purpose of paying introductory fees to the introducer.


    You have been provided with Terms of Business and Privacy Statement documents.

    You have provided the information herein to enable our financial and / or mortgage advisor firm collect and
    process your data in compliance with General Data Protection Regulations.

    You may separately provide our financial and / or mortgage advisor firm with your permissions in compliance with
    General Data Protection Regulations (GDPR) in relation to your marketing preferences and can opt in and out of
    or change the marketing preferences at any time.

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