Introducer Enquiry Form

Introducing Firm: (required)

Contact Name: (required)

Product Requested: (required)
---MortgageLife AssuranceGeneral Insurance Wills & TrustsLasting Power of AttorneyOther

First Name: (required)

Surname Name: (required)

Number / Street: (required)

Town: (optional)

City / County: (optional)

Post Code: (required)

Day Time Number: (required)

Mobile Number: (optional)

Your Email: (required)

Age: (optional)

Marital Status: (optional)
Single MarriedGetting married shortlyDivorcedWidow/erCo-HabitingSeparatedCivil Partnership

Children: (optional)
 Yes No

Residential Status: (optional)
HomeownerRentingLiving with Family/Friends

Own More Then on property: (optional)
 Yes No

THIS SECTION IS ONLY REQUIRED IF THIS IS A MORTGAGE ENQUIRY

Mortgage Type:
---PurchaseRemortgageBuy-to-let PurchaseBuy-to-let Remortgage

Property Value:

Loan Required:

THIS SECTION IS ONLY REQUIRED IF THIS IS A LIFE INSURANCE ENQUIRY

Is this to replace an existing life insurance plan:
 Yes No

Type of Cover:
SingleJoint

Are any of the applicants smokers:
YesNo

Are the applicants in good health:
YesNo

Other Information

PLEASE READ CAREFULLY

By completing this form you acknowledging that you have obtained applicant’s permission to be contacted by
Niche Advice Limited and their details can be held on our database.