Mortgage Life Insurance | French Mortgage Direct

FIRST PERSON

SURNAME

FIRST NAME

DATE OF BIRTH

PLACE OF BIRTH

NATIONALITY

FULL ADDRESS (main place of residence)

EMAIL

TELEPHONE

HAVE YOU SMOKED OR VAPED IN THE LAST 24 MONTHS?
YES NO

HEIGHT (cms)

WEIGHT (kgs)

JOB TITLE

EMPLOYER

INDUSTRY

DO YOU TRAVEL OUTSIDE OF YOUR HOME COUNTRY FOR WORK?
YES NO

If YES, please state frequency and countries

DO YOU HAVE ANY HEALTH ISSUES?
YES NO

If YES, please detail

DO YOU ALREADY HAVE FRENCH LIFE INSURANCE?
YES NO

If YES, please advise which companies you hold policies with and amounts insured

DO YOU PRACTICE SPORTING ACTIVITIES CONSIDERED TO BE DANGEROUS EITHER FOR PLEASURE OR COMPETITIVELY?
YES NO

If YES, please provide details

MORTGAGE or LOAN INFORMATION

TOTAL MORTGAGE AMOUNT

TYOE OF MORTGAGE (interest only, capital repayment, bridging loan)

INTEREST RATE & DURATION

BANK & BRANCH

CONTACT PERSON

TELEPHONE & EMAIL

FIRST PERSON

AMOUNT TO BE INSURED PER BORROWER (% of loan)

RISK REQUIRED (if known – DC/PTIA or DC/PTIA + ITT/IPT)

ESTIMATED DATE INSURANCE NEEDS TO BE IN PLACE FOR

PROPERTY ADDRESS

TYPE OF PURCHASE (ie 2nd home, rental)

SECOND PERSON

AMOUNT TO BE INSURED PER BORROWER (% of loan)

RISK REQUIRED (if known – DC/PTIA or DC/PTIA + ITT/IPT)

ESTIMATED DATE INSURANCE NEEDS TO BE IN PLACE FOR

PROPERTY ADDRESS

TYPE OF PURCHASE (ie 2nd home, rental)

ADDITIONAL REQUIREMENTS

WOULD YOU LIKE US TO OPEN A FRENCH BANK ACCOUNT FOR YOU?
YES NO

WOULD YOU LIKE TO OBTAIN A QUOTE FOR HOME INSURANCE FROM US?
YES NO

DO YOU HAVE ANY OTHER FRENCH INSURANCE REQUIREMENTS WE CAN HELP YOU WITH?
YES NO

WOULD YOU LIKE TO RECEIVE MORE INFORMATION ON CURRENCY?
YES NO

*Your contact details would be passed over to one of our trusted partners.

SIGNATURE

DATE

PLACE OF SIGNATURE

FULL NAME AND SIGNATURE OF PERSON COMPLETING FORM