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  Please use the form below. Fields that are marked * must be completed.  
 
  Surname*
 
  Initial(s)*
 
  Date of Birth*   [dd / mm / yy]
 
/ /  
 
 
  IMPORTANT:
  The information you send to Countrywide Assured is encrypted which means that your details will be transmitted to us securely. However, information transmitted from Countrywide Assured to your e-mail address cannot be transmitted securely.  
  For this reason we will not transmit your private or confidential information to you by e-mail.  
 
  To help us provide a prompt response, please confirm your current contact details below:
 
Address*
Postcode*
If any of your existing policies are held in joint names, please confirm whether the address above is relevant to both parties. (  = relevant to both parties).
 
 
Home Telephone Number*
 
STD:  
Work Telephone Number
 
STD:  
Mobile Telephone Number
 
  If you have a preferred contact number, please indicate this by clicking next to your preferred number.
 
         
         
  Please enter your policy number below (e.g. 123456A)
         
 
Policy Number*
  
If you would like to request information on more than one Policy, please raise a separate query for each Policy by using the appropriate link at the bottom of this form.
 
 
   
What is my current Policy value?
   
What is the projected value of my Policy at maturity?
   
Please send me a summary of the cover provided by my Policy
   
  If you have a different query about your Policy, please provide details in the box below.
   
 

 
 
 
 
  We will usually provide a postal response to your request. If it is possible to answer your question or query with a telephone call, when would you like us to contact you?
 
         
 
  If you have any special instructions or considerations regarding us contacting you,
please provide details in the box below.
   
 
 
         
 
The information you have provided will be used by Countrywide Assured for administration purposes.
You can ask at any time to see the information that is held about you (a fee may be payable for this service). Countrywide Assured or other subsidiary companies of Countrywide Assured may also use this information to up-date you by telephone, post or e-mail on our range of financial products and services.
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No
If you would prefer not to take advantage of this service, please indicate by selecting 'No'.
         
  IMPORTANT:    
 
The information you send to Countrywide Assured is encrypted which means that
your details will be transmitted to us securely.
 
     
 
OR
  
 
 
 

Alternatively, you can call our Customer Helpline free on 0800 262536 Monday to Friday,
between 8.00 a.m. and 6.00 p.m. A member of the team will be happy to help.
  
 


Countrywide Assured plc is authorised and regulated by the Financial Services Authority.
Countrywide Assured plc can only give advice on Life Assurance and Income Protection Insurance business of Countrywide Assured plc.

 
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