CGA - Country Gentlemen's Association

*Denotes Mandatory field

*First Name

*Surname

Title

Other Title

Address

Home Tel

Work Tel

Mobile Tel

*Email

Date of Birth

Smoker

yes

Place of Birth

Your Father\'s Place of Birth

National Insurace Number

Spouse\'s/Partner\'s Details

First Name

Surname

Title

Other Title

Date of Birth

Smoker

yes

Place of Birth

Your Father\'s Place of Birth

National Insurace Number

Children\'s Full Names and Dates of Birth

Your Assets

Joint assets

Spouse\'s/
Partner\'s Assets

Main Property

Commercial Property

Other Residential Property

Overseas Property

Chattels

Cash at Bank/Building Society

Gilts/Corporate Bonds

Premium Bonds/National savings

Investment Bonds

Unit Trusts

ISAs*, PEPs

*Have you used this years ISA allowance?

yes
no

yes
no

TESSAs/TOISA

Stocks and Shares

Private Company Shares

Other Investments

Please Specify

TOTALS


Your Occupation
Your Gross Annual Income:
Earned Income		Pension income
Rental Property income		Bank or Building Society Interest
Investment Income (please specify source)
Your Gross Annual Income:
Your Spouse\'s/Partner\'s Occupation
Your Spouse\'s/Partner\'s Annual Income:
Earned Income		Pension Income
Rental Property Income		Bank or Building Society Income
Investment Income (Please Specify Source)
Your Spouse\'s/Partner\'s Annual Income:

Please move down the form to complete other sections

Have you made a will?

You:

yes
no

Spouse/Partner:

yes
no

If yes, when was it last reviewed

You:

Spouse/Partner:

Please provide basic details of bequests below:

You:

To Spouse/Partner

or%

To Children

or%

To Charity

or%

Spouse/
Partner:

To Spouse/Partner

or%

To Children

or%

To Charity

or%

If married is there any bequest on the death of first spouse

You:

yes
no

Spouse/Partner:

yes
no

Do you have:

You:

Value

Spouse/
Partner:

Value

Pension Fund
(i.e. undrawn pensions)

yes
no

yes
no

Expectancies under wills or trust

yes
no

yes
no

Power over trusts

yes
no

yes
no

An interest in a business partnership/
company

yes
no

yes
no

Do you have a mortgage

yes
no

If yes, please provide the details below:

Name of Motgage Lender

Property Value

Outstanding mortgage amount

Type of Mortgage

Repayment
Interest Only

Current Interest Rate

Until

Early Redemption Penalty

Term of Mortgage

Years

Remaining

Years

Do you have:

Buildings Insurance

Yes
No

Sum Assured

Renewal Date

Contents Insurance

Yes
No

Sum Assured

Renewal Date

Do you have:

You:

Benefit

Spouse/
Partner

Benefit

Life Policies

Yes
No

Yes
No

Critical Illness Cover

Yes
No

Yes
No

Income protection Insurance

Yes
No

p.a.

Yes
No

p.a.

Private Medical Insurance

Yes
No

Yes
No


Please use the space below to give any information you feel relevant

If you are interested in any of the other services by the CGA, please tick below:

Private Banking Services

Will Writing Service

Other Insurances

Travel	Pet/Equine	Commercial
Classic Motor	Farms and Estates	Overseas Property
Marine	Public Liability	Professional Indemnity
Motor Fleet (Cars, Lorries, Coaches)

Would you like a free review of:

	Yes	No	In the future
Pensions
Long Term Care
Life/Critical Illness Cover
School Fees Planning
Mortgages
Investment Portfolio
Commercial Banking and Loan Arrangements
Personal Banking and Loan Arrangements