DATA CAPTURE FORM LIFE INSURANCE

Transcription

1 DATA CAPTURE FORM LIFE INSURANCE APPLICANT 1 APPLICANT 2 Title First Names Surname Date of Birth Marital Status Address Telephone In which country were you born? In the last 2 years, have you lived outside the UK, Channel Islands or Isle of Man for more than 6 months? Or other than holidays of less than 3 months, have you any intention of going outside the UK, Channel Islands or Isle of Man? What is your height? ft ins cm What is your weight st lbs kg What is your waist or dress size? ft st ins cm lbs kg Have you smoked in the last 12 months? How much do you smoke a day? Have you ever smoked any form of tobacco products? How old were you when you started? How old were you when you gave up? How much did you smoke per day?

2 How many units of alcohol do you drink in an average week? 1 pint of beer = 2 units; 1 glass of wine (175ml) = 2 units; 1 measure of spirits = 1 unit. Have you ever been given medical advice to reduce your alcohol intake or had, or been advised to have, any form of treatment or counselling relating to your alcohol consumption? Have you ever used illegal or recreational drugs or injected nonprescription drugs? e.g. cocaine, heroin, cannabis, ecstasy If yes, provide details Have you ever had an application on your life accepted on special terms, deferred or declined? Do you have, or are currently applying for, insurance cover with other insurance companies that means the total amount of insurance cover you have, or will have, with all insurance companies, including this application, will be higher than: 750,000 Life Cover OR 400,000 Critical Illness Cover? Have you ever tested positive for HIV, Hepatitis B or C or are you awaiting the result of such a test? Occupation How many hours do you usually work each week? Does your occupation involve manual work, driving or working at heights? Ignore driving to and from work If yes, please advise the percentage of your working day: Manual Work % % Driving How many business miles per annum % miles p.a. % miles p.a. Working at height % % Typical height ft / m ft / m Do you take part in any hazardous leisure activity? e.g. private aviation, diving, yachting or sailing, mountaineering or rockclimbing, motor sports, caving or potholing, parachuting, hang gliding. Do not include one off events such as parachute jumps for charity. How many times have you been off work, because of illness, an accident, or unemployment, for more than 2 weeks, in the last 5 years? Give reason(s) and time off on each occasion

3 MEDICAL QUESTIONS If answering yes to any of the following questions, complete details in additional information section Do you have, or have you ever had, any of the following? 1. Multiple sclerosis, Parkinson's disease, paralysis, epilepsy, Alzheimer's disease, dementia or cerebral palsy 2. Any neurological complaint, numbness, dizziness, involuntary shaking, loss of feeling, tingling of limbs or face, or temporary loss of muscle power or co ordination 3. Cancer, tumour, leukaemia, Hodgkin's disease, lymphoma, melanoma or any malignant condition 4. Irregular heartbeat, palpitations, heart murmur or heart disease including angina, heart attack or chest pains 5. Stroke, Transient Ischaemic Attack (TIA), brain haemorrhage or brain injury 6. Diabetes or sugar in the urine 7. Any nervous or mental disorder e.g. anxiety, stress, depression, schizophrenia, suicide attempt 8. Any hereditary disorder 9. Any disorder of the eyes or blurred or double vision, not fully corrected by glasses or contact lenses e.g. glaucoma, optic neuritis In the last 5 years have you had any of the following? 10. High blood pressure, or taken, or been advised to take, treatment for high blood pressure, or had, or been advised to have, your blood pressure monitored (other than as part of pregnancy) 11. High cholesterol, or taken, or been advised to take, treatment for raised cholesterol, or had, or been advised to have, your cholesterol levels monitored 12. Any cyst, growth, lump or swelling 13. Any mole or freckle that has changed in colour or appearance, bled, become painful or itchy, or increased in size 14. Asthma, bronchitis, pneumonia, emphysema or other lung disorder

4 15. Any disorder of the digestive system, gall bladder, stomach, bowel or liver e.g. gastric ulcer, duodenal ulcer, hepatitis, jaundice, colitis, Crohn's disease, hernia, irritable bowel syndrome. 16. Any disorder of the thyroid 17. Any disorder of the kidneys or bladder e.g. blood or protein in the urine or multiple urinary infections. 18. Any fit or blackout 19. Any disorder of the muscles, bones, joints or limbs e.g. arthritis, rheumatoid arthritis, gout 20. Any disorder of the back or neck e.g. slipped disc. 21. Any disorder of the skin or ear 22. Any disorder of the blood e.g. anaemia. 23. Only answer this question if you are female Any biopsy or ultrasound of the breast, uterus, cervix or ovary, or any abnormal cervical smear or mammogram You do not need to tell us about testing as a result of pregnancy 24. Only answer this question if you are male Any prostate enlargement or abnormal PSA (Prostate specific antigen), testicular or urinary problem. 25. Are you currently certified by a doctor as unfit for work? 26. Are you currently experiencing any symptoms or complaints for which you have not consulted a doctor? 27. Are you currently waiting for, or been advised to seek, any medical or surgical consultation or follow up? 28. In the last 5 years, other than for those conditions you have already told us about, have you: attended any other medical appointment, taken any other test or medication, or received any other treatment? 29. How many times a week do you exercise for at least 30 minutes? Moderate exercise generates an increase in temperature, breathing and heart rate. It can be structured exercise or sport such as running, swimming or cycling or a lifestyle activity such as a brisk walk to the shops, gardening or taking the dog for a walk.

5 30. In a typical working day do you spend two or more hours bending, walking, standing or lifting? If yes, please tell us how many hours of each you do 31. Before the age of 65 have any of your parents, brothers or sisters had: Heart attack or angina, Cardiomyopathy, Diabetes, Stroke, Breast, ovarian or colon cancer, Huntingdon s Chorea, Motor neurone disease, Polycystic kidney disease, Polyposis of the colon, or Multiple sclerosis If yes, please give further details including which relative was affected and the age at diagnosis 32. Is your father still alive? Age now if alive or age when died 33. Is your mother still alive? Age now if alive or age when died 34. Do you work in the Armed Forces (including reserve forces)?

6 ADDITIONAL INFORMATION Applicant 1 Question Number Diagnosis Date of Diagnosis Details of any treatment, tests and test results If diabetes or high blood pressure please provide latest reading and dates Current Condition

7 ADDITIONAL INFORMATION Applicant 2 Question Number Diagnosis Date of Diagnosis Details of any treatment, tests and test results If diabetes or high blood pressure please provide latest reading and dates Current Condition

8 DOCTOR S DETAILS APPLICANT 1 APPLICANT 2 DR Surgery Address Telephone Fax I understand that if I leave out any relevant information, or give incorrect information, it may lead to the contract being declared void. If my circumstances change in any way before the plan starts, I will tell you. I understand that if I do not do this, the contract may be declared void. By signing this permission I am allowing you to process my application using the information that I have given. You may also use this information to process any claim made on this plan. APPLICANT 1 APPLICANT 2 Signature Name Date Bank Details for Direct Debit Bank Name Sort Code Account Number Account Name Preferred Collection Date