Life Quote

Fields Marked * are Mandatory

Your Personal Details
Your First Name*
Your Last Name*
Your eMail*
Your Phone*
Cover Type Required	Life Cover Only Life Cover for Mortgage Protection Life Cover with Accelerated Critical Illness Life Cover for Mortgage Protection + Accelerated Critical Illness Life Cover with Stand-Alone Critical Illness Stand-Alone Critical Illness
Conversion	No Yes
Joint Cover Basis	One Life Basis Dual Life Basis Joint Life First Death Basis
Term in Years	5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40
Interest	Up to 6% 7% 8% 9% 10% 11% 12% 13%
Indexation	Not Indexed Indexed
Frequency	Monthly Yearly
Life Cover Sum Assured*
Critical Illness Sum Assured*
First Person's Details
Date of Birth*	DD/MM/YYYY (Min age 18. Max age 75)
Gender	Male Female
Smoker	No Yes
Second Person's Details
Date of Birth*	DD/MM/YYYY (Min age 18. Max age 75)
Gender	Male Female
Smoker	No Yes

Pat Treacy Insurance Brokers Ltd
261 Crumlin Road,
Crumlin, Dublin 12.

Tel. (01) 455 6577
Fax. (01) 455 8897
E: vivienne@pattreacy.ie