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Income protection claim

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Policy number

(Policy numbers are typically between 8-10 characters made up of letters and numbers)

First name

Surname

Phone number

Email address

Confirm email address

Date of birth

Address line 1

Address line 2 (optional)

Town (optional)

County (optional)

Postcode

Your condition or symptoms

Date when symptoms first started

Date when you were first unable to work

Are you still off work now?

Expected return to work date (if known) (optional)

Occupation

Annual salary before tax

GP details

Call back time (optional)

Any other comments? (optional)

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