Step 1 of 6

Who is the cover for? *

Do you have an active policy? *

What is your Date of Birth? *

What is your postcode? *

Are you a smoker? *

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A smoker is anyone who has smoked or used any form of nicotine replacement products in the past 12 months. Smoking products include cigarettes, tobacco, vaping, patches, cigars, and pipes. If you gave up smoking more than a year ago and no longer use any nicotine replacement products then you are classed as a non-smoker.

Do you have any pre-existing medical conditions? *

If yes, please provide condition(s) *

What's Your Title? *

What's your name? *

What's your email address? *

What's your telephone number? *

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