Please make sure you complete all fields, incomplete
surveys will not be entered into the prize draw.

Title:  Select... Mr Mrs Miss Ms Other
Forename: 
Surname: 
Address: 
 
Town: 
County: 
Postcode: 
Sex:  Select... Male Female
DOB:(dd/mm/yyyy)
Marital Status:  Select... Single Married Living Together Divorced/Separated Widowed
Home Telephone: 
Mobile:
Email: 

Your Partner's Details

Forename:
Surname:
DOB:(dd/mm/yyyy) 

1. How many cars in your household? Select... 0 1 2 3+

2. Please provide details about your main car (if any):

Make:
Model:
Is it? Select... Company Private
Bought: Select... New Used
When was it registered? (mm/yyyy)
3. When are you likely to replace your car? Select... 0-6mths 6-12mths 12-18mths 18-24mths

4. In which month do you renew your:

You

Partner

Car Insurance Select... Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Select... Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Motor Breakdown Cover Select... Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Select... Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Travel Insurance Select... Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Select... Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Health Insurance Select... Jan Feb Mar Apr May Jun Jul Aug Oct Nov Dec Select... Jan Feb Mar Apr May Jun Jul Aug Oct Nov Dec

Home

What type of house do you live in? Select... Detached Semi-Detached Flat Bungalow Maisonette Terrace
How many bedrooms? Select... 1 2 3 4 5 6 7 8 9 10+
When did you move to this address? (dd/mm/yyyy) 
Is your home: Select... Owned Privately Rented Council/Housing Assoc
What do you think is approximate value of your home?

Select... Under £100k £100-199k £200-299k £300-399k £400-499k £500-749k £750-999k £1m+

In which month do you renew your home insurance?

Home Contents Select... Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Buildings Select... Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Internet & Telephone

1. Do you have an internet connection? Select... Broadband Dial-up No

2. Do you have a mobile phone?

You: Select... Pre-pay Contract No
Partner: Select... Pre-pay Contract No

3. Which mobile network are you with?

You: Select... Orange O2 Vodafone T-Mobile Virgin Other
Partner: Select... Orange O2 Vodafone T-Mobile Virgin Other

Finance

What is your household income? Select... £0-24k £25-49k £50-74k £75-99k £100-150k £150+

Are you interested in any of the following Mortgage options?

 Switching lenders
 Remortgaging
 Debt Consolidation
 Lower Monthly payments

How many credit cards do you have?

You: Select... 0 1 2 3+
Partner: Select... 0 1 2 3+

What is your approx monthly balance?

You: Select... Under £200 £200-500 £500-1000 £1000+
Partner: Select... Under £200 £200-500 £500-1000 £1000+

Would you consider a loan?

You:  Yes No
Partner:  Yes No

The survey is run by TILT Ltd under the guidelines of the Data Protection Act and all information is processed in accordance with the Act. TILT Ltd may provide the information to other responsible organisations, who will use it for market research purposes. They may send you, by mail, email or other media, details of their offers and services. When answering questions for your partner, please check first that you have their permission to do so. If you or your partner would prefer not to receive communications from these organisations, please tick here partner