Quote





	Request an annuity quote In order to provide you with an appropriate annuity quote, we require certain details. This is because some types of annuity have certain conditions which must be met. For example, some annuities arising from an employer's pension scheme must escalate in payment by a certain level. The easiest way to request a quotation is to e-mail, fax or post any existing quote that you may have received. This will ensure that we quote accurately on the terms required. If this is not possible, then please complete the following quote request form as fully as possible and click on send at the end of the form. Don't worry if you can't complete the entire form - we'll let you know what's required. If you have any queries or require any assistance please E-MAIL us or telephone: 023 9235 2943.

Full Name of Person Completing this Form
Email Address of person named above
Date Completed
	THE ABOVE THREE FIELDS ARE MANDATORY OTHERWISE THIS FORM WILL NOT BE TRANSMITTED!


	Your Details

Title
Last Name
First Name(s)
Sex	Male Female
Street Address
Address (cont.)
Address (cont.)
County
Postal Code
Work Phone & STD
Home Phone & STD
Email (If different from above)
Date of Birth (DD/MM/YYYY)

Normal occupation during working lifetime

Do you smoke	Yes No
If yes, please state average number of manufactured cigarettes per day
or
Hand rolled ounces per week
Length of time as smoker	years

Do you have any medical conditions (Some providers offer higher annuities for certain medical conditions)


	Your Partner (Single Applicants click here to proceed to next section)

Title
Last Name
First Name(s)
Sex	Male Female
Street Address
Address (cont.)
Address (cont.)
County
Postal Code
Work Phone & STD
Home Phone & STD
Email (If different from above)
Date of Birth (DD/MM/YYYY)

Normal occupation during working lifetime

Do you smoke	Yes No
If yes, please state average number of manufactured cigarettes per day
or
Â Hand rolled ounces per week
Length of time as smoker	years

Do you have any medical conditions (Some providers offer higher annuities for certain medical conditions)


	Your Annuity

Please enter the total amount with which you wish to purchase an annuity	(Minimum £10,000)
Please select the source of the funds for the annuity	Other
Type of annuity required
Is any guarantee period required
Are Spouse's benefits required
Is escalation required
Is this illustration to be based on your current age?	Yes	No
If no, please state required age for illustration?	years of age.
How would you like us to reply?	E-mail	Phone	Post

Please enter any other additonal requirements or comments:

Registation number - 3933028 Registered address - 8 Claredon Road, Southsea, Hants, PO5 2EE, United Kingdom

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Just Annuities is a trading name of Wallace Nichols Financial Services Limited, which is authorised and regulated by the FSA.

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