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Please fill in the form below with your life cover requirements and contact details. An advisor will examine your details and call you back at the preferred time that you specify. If you wish to speak to one of our advisors right now, call us on 020 7519 4900.

Your life cover requirements:

Amount of life cover required:
Product type :
Do you require critical illness cover?
If so, what amount?
How long do you require cover?
(Years)

About you:

Name:
Name of 2nd applicant:
Telephone:
Alternative telephone:
Email address:
Postcode:
Address:
When is the best time to call you?
Where did you hear about us?
Additional notes (if needed):

Please note: The personal data relating to you gathered by us in your enquiry will be recorded electronically and only used in accordance with the Data Protection Act 1998. By submitting this form you are agreeing for us to contact you by telephone only for the purpose of this life cover enquiry.

YOUR HOME MAY BE REPOSSESSED IF YOU DO NOT KEEP UP REPAYMENTS ON YOUR MORTGAGE

© Clegg Gifford Private Clients, 2003-2008. All rights reserved.
* We charge a non-refundable application fee for arranging your mortgage, payable with the mortgage application. The exact amount of this fee will depend on the amount of your mortgage and the complexity of your application. This fee structure is as follows: £395 for mortgages under £500,000, £795 for mortgages, between £500,000 and £1,000,000, £1,195 for mortgages over £1,000,000, £1,995 for complex mortgage applications. This will be determined by us and agreed with you prior to any chargeable work being undertaken. In addition we will be paid commission from the lender.
Clegg Gifford Private Clients is authorised and regulated by the Financial Services Authority. The Financial Services Authority does not regulate buy to let mortgages, second charge secured loans or overseas mortgages. Clegg Gifford Private Clients is a trading name of Clegg Gifford Private Clients Ltd, and an associated company of Clegg Gifford & Co Ltd, Lloyds' Broker, and Tradex Insurance Company Ltd. Registered in England and Wales No. 5070990 at 128/129 Minories, London, EC3N 1PB

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Your life cover requirements:

About you: