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Age

Under 18

18-30

31-49

50-64

65+

Sorry we can do 18+ age...

Employment Status

Employed full time

Employed part time

Self employed

Not currently employed

Retired

Marital status

Married / Civil partnership

Co habiting

Engaged

Widowed

Divorced

Separated

Single

Sex

Male

Female

Non-Binary

1. Are you a homeowner?

Yes

2. How do you own it?

a. Solely

b. Jointly with others

3. Do you have a mortgage?

a. Yes

b. No

i. When is it due for renewal?

1. Within 6 months

2. Within 1 year

3. Within 2 years

4. More than 2 years

5. Not sure

4. Do you have mortgage protection (a policy that will pay off the mortgage on your death)

a. Yes

b. No

i. Would you like a free review of your policy?

1. Yes

2. No

5. Do you have critical illness protection? (a policy that will pay you if you are seriously ill)

a. Yes

b. No

i. Would you like a free review of your policy?

Yes

i. When you like to protect your income with a free quote?

Yes

i. When you like to secure your family’s future with a free quote?

1. Immediately

2. Within 30 days

3. Within 60 days

4. Not now

6. Do you have any life insurance? (a policy that will pay you a lump sum on your death)

a. Yes

b. No

i. Would you like a free review of your policy?

Yes

i.When you like to protect your family with a free quote?

Yes

7. Do you have a Will?

a. Yes

b. No

i. When was your Will made?

1. Within 1 year

2. Within 5 years

3. More than 5 years ago

i. When you like to get peace of mind for your loved ones with a free Will consultation?

1. Immediately

2. Within 30 days

3. Within 60 days

4. Not now

a. Would you like a free review of your Will?

i. Yes

ii. No

a. Would you like a free review of your Will?

i. Yes

ii. No

8. Do you have Powers of Attorney in place? (a legal documents that helps trusted people manage your affairs if you are unable to)

i. Yes

ii. No

i. Which Power of Attorney do you have?

1. Property & Finance LPA

2. Health & Welfare LPA

3. Both

a. When are you planning to do the Health & Welfare LPA?

i. Immediately

ii. Within 30 days

iii. Within 60 days

iv. Not now

a. When are you planning to do the Property & Finance LPA?

i. Immediately

ii. Within 30 days

iii. Within 60 days

iv. Not now

i. When would you like to ensure your affairs are managed by a trusted person if you aren’t able to, with a free consultation meeting?

i. Immediately

ii. Within 30 days

iii. Within 60 days

iv. Not now

9. Who is your current gas & electricity supplier?

a. When is your contract due for renewal?

Within 3 months

Within 6 months

Within 1 year

More than 1 year

Not sure

10. Do you run your own business?

a. Yes

b. No

i. What type of business is it?

1. Limited Company

2. LLP

3. Partnership

4. Sole trader

Thank you have now been entered into the Survey Prize Draw. Main Prize – HOLIDAY IN INDIAN

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Family Name

Phone/Mobile

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