Title
(e.g. Mr, Mrs, Ms, Miss) 		  
Forename/s  
Surname  
Your date of birth
Gender
 
Are you employed? (?)
Do you Currently hold a mortgage?
Must have a mortgage to be eligible for this insurance
Do you wish to transfer from an existing payment protection policy?
If 'Yes' your existing policy is over 6 month is old, your premiums are fully paid and you have not claimed under your existing policy.
Is this a new or existing mortgage?
 
Occupation
Working Pattern
You must be working a minimum of 18 hours per week to be eligible for this insurance
Employer  
Home Address Address 1
Address 2
Town or City
County
Postcode
Country
Daytime telephone number  
Mobile Phone  
     
Evening time telephone number  
E-mail address This is required to confirm receipt of your application
E-mail Confirmation This is required to confirm receipt of your application
Select cover option (?)
ASH = Accident, Sickness, Hospitalisation.


ASHU = Accident, Sickness, Hospitalisation, Unemployment.
Benefit period (?)
Net Monthly Income (NMI) (?) €   Net monthly income
= salary less tax & national insurance contributions
Your Monthly Mortgage Repayments are €    
Calculate Maximum Monthly Benefit (?) €    
Your maximum monthly benefit is the lesser of 110% of your monthly Mortgage Repayment or 75% of your net monthly income subject to a maximum € 2,000 per month.
Cover required (?) €    
Your monthly benefit amount is €   This is the maximum amount of your monthly claim
Premium (?) €    
 

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Instant Cover on-line! Click & Insure can provide you
with a great online quote for Mortgage Payment Protection
Insurance, Wedding Insurance and Travel Insurance.

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Wedding Insurance

Travel Insurance

Click and Insure Ltd is regulated by the Financial Regulator as a Multi Agency Intermediary. Registered Office 34a Dollymount Park, Clontarf, Dublin 3. Registered in Ireland. Company Reg no:385401. A private company limited by shares and having share capital. Directors: Nigel Darragh, MF Darragh