SMART Insurance Quote Form Application Type*Single ApplicationJoint ApplicationsPersonal DetailsName Applicant 1* Mr.Mrs.MissMs.MasterDr. Prefix First Last Name Applicant 2* Mr.Mrs.MissMs.MasterDr. Prefix First Last Date of Birth Applicant 1* Date Format: DD slash MM slash YYYY Date of Birth Applicant 2* Date Format: DD slash MM slash YYYY Smoker Status Applicant 1*YesNoSmoker Status Applicant 2*YesNoPhone/mobile Applicant 1Phone/mobile Applicant 2Email Applicant 1* Email Applicant 2* Address Applicant 1 Street Address Address Line 2 City ZIP / Postal Code Address Applicant 2 (Enter if different to Applicant 1) Same as Applicant 1 Street Address Address Line 2 City ZIP / Postal Code Life Cover Amount RequestedHow much Life cover do you want? Applicant 1*How much Life cover do you want? Applicant 2*Existing Life Cover HeldTotal Current Life Insurance. Applicant 1Total Current Life Insurance. Applicant 2Applicant 1 - Do you have any Health Issues or are you on any medication?*NoYesApplicant 2 - Do you have any Health Issues or are you on any medication?*NoYesDescribe any current health issues. Applicant 1Describe any current health issues. Applicant 2
