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Client form

Life Assurance Authority

Complete this letter of authority so My Mortgage & Protection Experts can contact your insurer(s) and obtain up-to-date benefit and policy information. A policy reference is required for each policy.

Your details

Full name*

Email address*

Date of birth*

Telephone

National Insurance number*

Current home address*

Time at current address (years)*

Previous address

Why we ask: Insurers sometimes hold an old address on file if the policy was taken out before you moved and never updated. Add any previous address here so the insurer can match your record.

I have a previous address the insurer may have on file.

Policies

Add one row per policy you'd like us to enquire about. The policy reference (number) is required — this is how the insurer locates your record. If you can't find it, please contact your adviser before completing this form.

Policy 1

Provider / insurer*

Contract type*

Policy reference / number*

Additional notes (optional)

Signature

By signing below you authorise My Mortgage & Protection Experts Ltd to contact the insurer(s) listed above and request up-to-date benefit and policy information on your behalf.

Draw your signature hereor drop / paste / upload an image

Draw, or drop/paste an image (PNG or JPG, max 2 MB). Uploading replaces the current signature.

For compliance we record the date and time you sign, your IP address, browser user agent and a unique document reference. This forms your digital audit trail.

Declaration*I confirm the information above is accurate and authorise My Mortgage & Protection Experts Ltd to obtain policy and benefit information from the insurer(s) listed. I understand a copy of this authority (including my digital signature and audit trail) will be retained by MMPE and may be shared with the insurer to verify my consent.

Your information is sent securely to My Mortgage & Protection Experts and used only for advising on your policy.