Medical Questionnaire

Please fill in this Standard Medical Questionnaire and submit it back to us. This will allow us to see if you will qualify for Cover.
Note; If there are more than 1 person applying for cover, then both need to fill out the application.
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Medical History
Have you ever had any of the following?
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26. Have you ever had any of the following?

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Apart from anything you have already told us about, have you:

27(d) Please give details of the relative(s) in question;

28. COVID-19

Recent Medical Issues

Apart from anything you have already told us about, during the last 3 years have you:

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Apart from anything you have already told us about, during the last 5 years have you:

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2nd Person Medical Information
Please fill out the following information for the second person on the policy:
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2nd Person Medical Hisory

Have you ever had any of the following?

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7. Have you ever had any of the following?
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10. Have you ever had any of the following?
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2nd Person Recent Medical Issues
12. Apart from anything you have already told us about, during the last 3 years have you:
2nd Person Family History
13. Please fill out the family medical history questions below for the 2nd person on this policy.
23. Please give details of the relative(s) in question;
Thank you for taking the time to complete this questionnaire. Hit Submit to save your data.