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Immediate Needs Annuity Quote
Immediate Needs Quote
An immediate needs quote can give you an indication of the cost of long term care for an elderly relative entering a residential or nursing home. The annuity cost is often four to five times the annual income required.  
  * Indicates a 'Required field', which must be filled before submitting the form.  
My Details
  Your details are only used in relation to your immediate needs annuity enquiry. We have assumed you are completing this form on behalf of the applicant, therefore please state your relationship with them (e.g. son, daughter, friend, care home manager etc) and give your name and contact details:  
     Are you completing form for the applicant?:
Yes: No:
  * Relationship with applicant:  
     Timescale considered for changes:  
     How did you find our website:  
  * Name:
  * Address 1:  
     Address 2:  
  * Town/City:  
     County/Country (if overseas):  
  * Postcode:  
  * Email address:  
  * Phone number:  
  * Applicant's Name:
  * Applicant's date of birth:
  * Applicant's gender:  
Funds for Annuity
  Please indicate the total annual cost of care. The income provided by an annuity is usually the annual care costs less existing annual income (you may wish to add more annuity income to cover personal expenses).

Please also indicate below if you have secured NHS funding or support from the Local Authority to cover some of the costs of care and this should be included in the existing annual income.
  * Total annual cost of care:  
  Existing annual income:  
  Income provided by the annuity:  
     Or Lump sum available:  
     Funding from the NHS?:
Yes: No:
     Funding from the Local Authority?:
Yes: No:
  Please complete the following if you are currently being provided with care:  
Not currently receiving care:  
Care Home (with nursing care):  
Care Home (no nursing care):  
Own Home:  
     Duration of care to date (if applicable):  
Disease and Impairments
  Please indicate if the applicant suffers from any of the following diseases or impairments and the severity (ADL means Activities of Daily Living):  
1. Cancer 2. Stroke
  Date diagnosed:  
  Date diagnosed:  
  Not applicable  
  Not applicable  
  Cured in short term  
  Minor disability, some ADLs  
  Receiving treatment  
  Major disability, total care  
  Receiving palliative care  
3. Diabetes 4. Heart Failure
  Date diagnosed:  
  Date diagnosed:  
  Not applicable  
  Not applicable  
  Non insulin dependent  
  Controlled with medication  
  Insulin dependent  
  Medication but still symptoms  
5. Pneumonia 6. Respiratory Disease
  Date diagnosed:  
  Date diagnosed:  
  Not applicable  
  Not applicable  
  1-2 episodes in the last year  
  Intermittent oxygen insufflation  
  3+ episodes in the last year  
  Daily oxygen insufflation  
7. Contracture 8. Pressure Ulcers
  Date diagnosed:  
  Date diagnosed:  
  Not applicable  
  Not applicable  
  Partial stiffening of 1+ joints  
  Controlled with medication  
  Severe stiffening of 1+ joints  
  Medication but still symptoms  
9. Nutrition  
  Date diagnosed:  
  Not applicable  
  Requires assistance  
  Artificial nasogastic / PEG feeding  
  Please indicate if one or more of the following disabling diseases
have been diagnosed:
  No Yes   Date Diagnosed
10. Dementia  
11. Multiple Sclerosis  
12. Motor Neurone Disease  
13. Parkinson's Disease  
Activities of Daily Living
  Please indicate if you or your relative has difficulty with any of the following Activities of Daily Living:  
  1. Communication  
  Good/fluent, easy to understand  
  Moderate, sometimes difficult to understand but makes needs known  
  Poor or unintelligible cannot make needs known  
  2. Orientation  
  Alert or lucid and responsive  
  Sometimes forgetful, vague with lucid periods  
  Confused with no lucid periods  
  3. Mobility  
  a) Toilet use:-  
  Independent (clothing, wiping)  
  Needs some help with clothing, getting on/off toilet but can do some alone  
  Requires full assistance and bowel care, changing clothes and linen daily  
  b) Transfer (bed to chair and back):-  
  Minor help, can sit unaided but needs some limited assistance  
  Major help, no sitting balance and needs one or two people to assist  
  c) Dressing:-  
  Independent ( eg buttons, zips, laces)  
  Needs some assistance with fasteners, getting in and out of the bath  
  Requires full assistance  
  d) Stairs:-  
  Can walk up and down stairs unaided  
  Requires some assistance  
  Cannot walk up or down stairs  
  4. Continence  
  Occasional accident  
  Incontinent and needs indwelling catheter and protective clothing  
  Additional comments you would like to make regarding this form:  
Sending the form
  This quote service is free of charges and by submitting this form you are not under any obligation or commitment to purchase an annuity through us.

Your personal data is protected in accordance with out Privacy Policy and the information you are sending is secured by GeoTrust and verified by Equifax.

Please ensure you have reviewed our Terms and Conditions before continuing.
   Notes to help you
Our website is protected by GeoTrust and verified by Equifax to ensure any data you share with us is secure.

An immediate needs annuity quote gives you an indication of the fund required for care.

It is suitable for an elderly relative entering a residential or nursing home. The cost of this cover is usually 4 to 5 times the annual income required (eg £10,000 in annual income would need capital
of between £40,000-£50,000).

For guaranteed offers from providers, further medical information would be needed including a report from a relatives Doctor in order to secure the best offers from providers.

   What happens now?
Free Quote
By submitting this form you are not under any obligation or commitment to purchase an immediate needs annuity from us. The quote service will give you an estimate of the income or fund required for care fees and is free of charge.

Full Care Report
A full care report on your relatives care options includes insurance, investment and immediate needs annuity.

The report secures guaranteed offers from the immediate needs providers requiring more detailed information about the applicant requiring a form to be completed which we would send to you.

Providers request information from the Doctor in order to make their best guaranteed offer. The fee is from £500 for this service.

How we can help
If you need further information or wish to proceed with an immediate needs annuity guaranteed offer our expert advisers can process all paperwork on your behalf and deal with the provider's administration.

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