6. Doctor Name/Practice

7. Doctor Address

8. The length of time you have been with this doctor?

9. Do you smoke or vape ?

Yes

No

If you smoke, how many cigarettes do you smoke per day?

10. What is your height?

11. What is your weight?

12. How many units (1 pint/1 glass of wine = 2 units) of alcohol do you consume in an average week?

13. Have you ever been given medical advice to reduce your alcohol intake?

Yes

No

14. Have you ever used illegal/recreational drugs?

Yes

No

15. Have you lived, worked, or travelled outside of the European Union, United Kingdom, North America, Australia, New Zealand or Japan in the last 2 years or is it your intention to do so in the next 2 years?

Yes

No

16. Do you intend to take part in any hazardous sports? e.g. aviation, motorsports

Yes

No

17. Have you ever had an application for Life, Specified Serious illness or Income Protection cover declined, postponed or had special terms-applied to it?

Yes

No

Please provide details of type and amount of cover, name of insurer and if applicable, reason for special terms.

Medical History

Have you ever had any of the following?

18. Have you ever had any form of Cancer, Tumour, Lymphoma, Hodgkin's disease, Leukaemia, Melanoma or any brain or spinal growth or cysts?

Yes

No

18-A) When were you diagnosed with this issue? (Month and year)

18-B) Are you:

18-C) When was your last checkup, and what was the outcome?

19. Have you ever had disease or disorder of the heart (including valves) or circulatory system, heart attack, angina, cardiomyopathy, disease of the arteries or peripheral vascular disease?

Yes

No

19-A) When were you diagnosed with this issue? (Month and year)

19-B) Are you:

19-C) When was your last checkup, and what was the outcome?

20. Have you ever had a stroke, transient ischaemic attack (TIA/mini-stroke), brain haemorrhage, aneurysm, brain injury or surgery to your blood vessels in the brain or neck?

Yes

No

20-A) When were you diagnosed with this issue? (Month and year)

20-B) Are you:

20-C) When was your last checkup, and what was the outcome?

21. Have you ever had multiple sclerosis, Parkinson’s disease, epilepsy, fit or seizure, Alzheimer’s disease, dementia, cerebral palsy, muscular dystrophy, motor neurone disease or had any other neurological disorder?

Yes

No

21-A) When were you diagnosed with this issue? (Month and year)

21-B) Are you:

21-C) When was your last checkup, and what was the outcome?

22. Have you ever had bipolar disorder, manic depression, schizophrenia, psychosis or eating disorders, or have you ever required hospital treatment or a referral to a psychiatrist or psychologist as a result of any mental illness?

Yes

No

22-A) When were you diagnosed with this issue? (Month and year)

22-B) Are you:

22-C) When was your last checkup, and what was the outcome?

23. Have you ever had diabetes, raised blood sugar or sugar in the urine, thyroid problems, goitre or glandular fever?

Yes

No

23-A) When were you diagnosed with this issue? (Month and year)

23-B) Are you:

23-C) When was your last checkup, and what was the outcome?

24. Have you ever had a positive test for HIV/AIDS or Hepatitis B or C, or are you awaiting the results of such a test?

Yes

No

24-A) When were you diagnosed with this issue? (Month and year)

24-B) Are you:

24-C) When was your last checkup, and what was the outcome?

25. Have you ever had and issues relating to raised blood pressure, raised cholesterol, chest pain or irregular heart beat?

Yes

No

25-A) When were you diagnosed with this issue? (Month and Year)

25-B) Are you:

25-C) When was your last checkup, and what was the outcome?

26. Have you ever had depression, anxiety, stress, insomnia, chronic fatigue syndrome, eating disorders or have you been referred to a psychiatrist or hospital clinic as a result of any mental illness?

Yes

No

26-A) When were you diagnosed with this issue? (Month and year)

26-B) Are you:

26-C) When was your last checkup, and what was the outcome?

27. Have you ever had any numbness pins and needles, optic neuritis, double/blurred vision, tremor, tingling, muscle weakness, loss or reduced power in limbs, persistent tiredness or fatigue? Please answer ‘yes’ whether you have been seen by a doctor for any other these listed issues?

Yes

No

27-A) When were you diagnosed with this issue? (Month and year)

27-B) Are you:

27-C) When was your last checkup, and what was the outcome?

28. Have you ever had any issues relating to any form of arthritis, gout, joint-or ligament pain or neck, back, spine or muscle pain or stiffness?

Yes

No

28-A) When were you diagnosed with this issue? (Month and year)

28-B) Are you:

28-C) When was your last checkup, and what was the outcome?

29. Have you ever had Any disorder affecting your ears or hearing, or your eyes or vision that is not wholly corrected by spectacles or lenses?

Yes

No

29-A) When were you diagnosed with this issue? (Month and year)

29-B) Are you:

29-C) When was your last checkup, and what was the outcome?

30. Have you ever had tumour, lump, cyst, polyp, growth or a mole or naevus that has bled, changed in appearance or become painful? Please answer ‘yes’ whether you have been seen by a doctor or not.

Yes

No

30-A) When were you diagnosed with this issue? (Month and year)

30-B) Are you:

30-C) When was your last checkup, and what was the outcome?

31. Have you ever had any of the following;

Asthma, bronchitis, sarcoidosis, emphysema or any other disorder affecting your lungs or breathing?

Yes

No

31-A) When were you diagnosed with this issue? (Month and year)

31-B) Are you:

31-C) When was your last checkup, and what was the outcome?

32. Have you ever had any disorder of the digestive system, liver, stomach, pancreas or bowel (including any ulcer, hepatitis, colitis, Crohn's disease or Barrett’s osophagus)?

Yes

No

32-A) When were you diagnosed with this issue? (Month and year)

32-B) Are you:

32-C) When was your last checkup, and what was the outcome?

33. Have you ever had any of the following?

Haemochromatosis, anaemia, vitamin b12 deficiency, clotting disorders or any other blood disorders?

Yes

No

33-A) When were you diagnosed with this issue? (Month and year)

33-B) Are you:

33-C) When was your last checkup, and what was the outcome?

34. Have you ever had any disorder of the kidney, bladder or prostate, including blood or protein in the urine or raised PSA (Prostate Specific Antigen)?

Yes

No

34-A) When were you diagnosed with this issue? (Month and year)

34-B) Are you:

34-C) When was your last checkup, and what was the outcome?

35. Have you ever been regularly prescribed medication or treatment lasting for a period of 4 consecutive weeks or more, or have you been under review from your doctor or a medical professionals? You do not need to tell us about contraception, fertility, dental treatment or reviews purely in relation to pregnancy.

Yes

No

35-A) When were you diagnosed with this issue? (Month and year)

35-B) Are you:

35-C) When was your last checkup, and what was the outcome?

Recent Medical Issues

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

36(a) Been referred to a specialist, undergone or been advised to have any tests or investigations? For example: Abnormal smear or mammogram, biopsy, colonoscopy, scans or blood tests. You do not need to tell us about investigations which were purely for pregnancy, infertility or simple fractures.

Yes

No

36(b) Are you awaiting referral, investigations, results or treatment, for anything else or do you have any other symptoms for which you have not yet sought medical advice? For example: Bleeding from the bowels or change in bowel habit, persistent cough, weight loss, onset of fits or seizures, dizziness, blackouts or fainting.

Yes

No

36(c) Have any of your natural parents, brothers or sisters ever been diagnosed with or died from any of the following before age 60? Heart Attack or Angina, Cancer (including Leukemia or Lymphoma), Multiple Sclerosis, Muscular Dystrophy, Motor Neuron Disease, Cardiomyopathy, Poly-cystic Kidney Disease, Familial Colon Polyps, Stroke, Diabetes, Huntington's Disease, Alzheimer’s Disease, Parkinson’s Disease, Haemochromatoasis.

Yes

No

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

Type of Relative

Condition

Age of Diagnosis

If you have had any tests or check-ups as a result of a relative’s medical condition, please give details here. In line with the Disability Act 2005, the results of any genetic tests should not be disclosed.

37. COVID-19

Have you ever been diagnosed with COVID-19?

Yes

No

Have you experienced any COVID 19-like symptoms in the last 3 months?

Yes

No

The date you were diagnosed?

What symptoms did you have?

Did you attend a hospital?

Are you fully recovered?

38. Are two people applying for cover? ( You and your partner )

Yes

No

2nd Person Medical Information

Please fill out the following information for the second person on the policy:

1. Name of the Person *

Phone Number

Email Address

2. Do you smoke or vape (For 2nd Person)?

Yes

No

If you smoke, how many cigarettes do you smoke per day (For 2nd Person)?

4. What is your weight (For 2nd Person)?

5. How many units (1 pint/1 glass of wine = 2 units) of alcohol do you consume in an average week (For 2nd Person)?

6. Have you ever been given medical advice to reduce your alcohol intake (For 2nd Person)?

Yes

No

7. Have you ever used illegal/recreational drugs (For 2nd Person)?

Yes

No

8. Do you intend to take part in any hazardous sports? e.g. aviation, motorsports (For 2nd Person)

Yes

No

9. Have you ever had an application for Life, Specified Serious illness or Income Protection cover declined, postponed or had special terms-applied to it (For 2nd Person)?

Yes

No

Please provide details of type and amount of cover, name of insurer and if applicable, reason for special terms (For 2nd Person).

Name & address of current doctor (For 2nd Person)

2nd Person Medical Hisory

1. Any form of cancer, tumour, lymphoma, Hodgkin's disease, leukaemia, melanoma or any brain or spinal growth or cysts (For 2nd Person)?

Yes

No

1-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

1-B) Are you: (For 2nd Person)

1-C) When was your last checkup, and what was the outcome (For 2nd Person)?

2. Raised blood pressure, raised cholesterol, chest pain or irregular heart beat (For 2nd Person)?

Yes

No

2-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

2-B) Are you: (For 2nd Person)

2-C) When was your last checkup, and what was the outcome (For 2nd Person)?

3. Numbness. pins and needles, optic neuritis, double/blurred vision, tremor, tingling, muscle weakness, loss or reduced power in limbs, or persistent tiredness or fatigue? Please answer ‘yes’ whether you have been seen by a doctor or not (For 2nd Person).

Yes

No

3-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

3-B) Are you: (For 2nd Person)

3-C) When was your last checkup, and what was the outcome (For 2nd Person)?

4. Any form of arthritis, gout, joint-or ligament pain or neck, back, spine or muscle pain or stiffness (For 2nd Person)?

Yes

No

4-A) When were you diagnosed with this issue? (Month and year)

4-B) Are you: (For 2nd Person)

4-C) When was your last checkup, and what was the outcome (For 2nd Person)?

5. Any disorder affecting your ears or hearing, or your eyes or vision that is not wholly corrected by spectacles or lenses (For 2nd Person)?

Yes

No

5-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

5-B) Are you: (For 2nd Person)

5-C) When was your last checkup, and what was the outcome (For 2nd Person)?

A tumour, lump, cyst, polyp, growth or a mole or naevus that has bled, changed in appearance or become painful? Please answer ‘yes’ whether you have been seen by a doctor or not (For 2nd Person).

Yes

No

6-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

6-B) Are you: (For 2nd Person)

6-C) When was your last checkup, and what was the outcome (For 2nd Person)?

7. Have you ever had any of the following?

Asthma, bronchitis, sarcoidosis, emphysema or any other disorder affecting your lungs or breathing (For 2nd Person)?

Yes

No

7-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

7-B) Are you: (For 2nd Person)

7-C) When was your last checkup, and what was the outcome (For 2nd Person)?

8. Regularly been prescribed medication or treatment lasting for a period of 4 consecutive weeks or more, or have you been under review from your doctor or a medical professionals? You do not need to tell us about contraception, fertility, dental treatment or reviews purely in relation to pregnancy (For 2nd Person).

Yes

No

8-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

8-B) Are you: (For 2nd Person)

8-C) When was your last checkup, and what was the outcome (For 2nd Person)?

9. Any disorder of the digestive system, liver, stomach, pancreas or bowel (including any ulcer, hepatitis, colitis, Crohn's disease or Barrett’s osophagus) (For 2nd Person)?

Yes

No

9-A) When were you diagnosed with this issue? (Month and year)

9-B) Are you: (For 2nd Person)

9-C) When was your last checkup, and what was the outcome (For 2nd Person)?

10. Have you ever had any of the following?

Haemochromatosis, anaemia, vitamin b12 deficiency, clotting disorders or any other blood disorders (For 2nd Person)?

Yes

No

10-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

10-B) Are you: (For 2nd Person)

10-C) When was your last checkup, and what was the outcome (For 2nd Person)?

11. Any disorder of the kidney, bladder or prostate, including blood or protein in the urine or raised PSA (Prostate Specific Antigen) (For 2nd Person)?

Yes

No

11-A) When were you diagnosed with this issue? (Month and year) (For 2nd Person)

11-B) Are you: (For 2nd Person)

11-C) When was your last checkup, and what was the outcome (For 2nd Person)?

2nd Person Recent Medical Issues

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

12(a) Been referred to a specialist, undergone or been advised to have any tests or investigations? For example: Abnormal smear or mammogram, biopsy, colonoscopy, scans or blood tests. You do not need to tell us about investigations which were purely for pregnancy, infertility or simple fractures (For 2nd Person).

Yes

No

12(b) Are you awaiting referral, investigations, results or treatment, for anything else or do you have any other symptoms for which you have not yet sought medical advice? For example: Bleeding from the bowels or change in bowel habit, persistent cough, weight loss, onset of fits or seizures, dizziness, blackouts or fainting (For 2nd Person).

Yes

No

2nd Person Family History

13. Please fill out the family medical history questions below for the 2nd person on this policy.

Have any of your natural parents, brothers or sisters ever been diagnosed with or died from any of the following before age 60? Heart Attack or Angina, Cancer (including Leukemia or Lymphoma), Multiple Sclerosis, Muscular Dystrophy, Motor Neuron Disease, Cardiomyopathy, Poly-cystic Kidney Disease, Familial Colon Polyps, Stroke, Diabetes, Huntington's Disease, Alzheimer’s Disease, Parkinson’s Disease, Haemochromatoasis (For 2nd Person).

Yes

No

23. Please give details of the relative(s) in question;

Type of Relative (For 2nd Person)

Condition (For 2nd Person)

Age of Diagnosis (For 2nd Person)

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