Full Name & Title. Date of birth. Marital status. Address. Smoker/Non-Smoker

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2 Full Name & Title Date of birth Marital status Address First Person Second Person Smoker/Non-Smoker (Have you used any tobacco/nicotine/electronic cigarettes products in the last 12 months?) Doctors Surgery & Name of Doctor Telephone Surgery Address Nationality (British national, permanent right to reside or type of visa & time remaining) Bank Details for your Policy (Sort Code and Account Number)

3 Trustee & Beneficiary Details Your Height (Ft & Inches/ M & Cm) Your Weight (stones & lbs/ kgs) Waist Measurement Skirt/Dress Size Have you lost more than 7 lbs in the last 2 years? How many units of alcohol do you drink per week? Note: A unit of alcohol is equivalent to one standard glass of wine/a single measure of spirits/half a pint of beer, lager or cider Have you ever been advised to reduce your alcohol intake for medical reasons? If yes please tell us the advice and why it was given. Do you use any tobacco products or nicotine replacement products (incl. electronic cigarettes)? If yes how many

4 cigarettes, cigars or grams of tobacco per day? If nicotine replacement please specify. Have you ever used any tobacco products? If yes please tell us when you did, when you stopped and how many. (mm/yy) Have you ever been advised to reduce your smoking intake for medical reasons? If yes please tell us the advice and why it was given. How many times do you exercise per week for more than 30 minutes? Have you had any time off work for illness or injury for more than 5 days in the last 2 years? Do you currently or intend to take part in any hazardous sports or activities? E.g. motor sports, private aviation, diving, climbing/mountaineeri ng, or other? Have you travelled, worked or resided OUTSIDE of the UK for more than 30 days in the last five years or do you plan to do so? If yes please state duration, where, when

5 (mm/yy) and the reason for travel. Have you ever had surgery or received blood products when you have been outside the EU? Do you intend to reside outside of the UK in the future? Employment status e.g. employed/ self employed Occupation (give specific details) and Industry Annual Salary How long have you been in your current job? (yy/mm) How many hours do you work per week? How is your time at work split between the following activities? Clerical/administrative % Manual% In your occupation do you work at heights over 40ft? If yes please state average and maximum working heights. Do you work in a hazardous environment? If yes please briefly describe the hazards. Do you work with dangerous substances or heavy machinery? If yes

6 please give details. How many business miles do you drive per year? Are you a member of Her Majesty s Forces or volunteer reserve forces? If yes are you required to travel to areas of conflict and details of your travel. Do you have any criminal or motoring convictions in the last 5 years? If answering yes to any of the following please complete a separate sheet per medical condition. Please indicate how many supplementary sheets used here Do you have or have you ever had or asked to have tests for any of the following: Heart disease/abnormality, including heart attack, angina, heart defects from birth or heart surgery/heart valve disease? Diabetes or sugar in the urine? What type of diabetes and how is it controlled? Cancer, leukaemia, Hodgkin s disease, lymphoma, brain or spinal tumour? A disorder of the brain (including any caused by injury), brain haemorrhage, or a stroke?

7 Epilepsy? Multiple sclerosis, Parkinson s disease, any form of paralysis, Alzeimer s disease, dementia or cerebral palsy? Any other disorder of the nervous system not already mentioned? Disease or disorder of the arteries (including disease of the legs or of the aorta)? Malignant Tumour including cancer? Mental illness that has required hospital treatment or referral to a psychiatrist? Any allergies/skin conditions that place restrictions on your normal daily activities or ability to carry out any aspect of your occupation? The next two questions are for females only Have you had any changes to your breast regardless of consultation with a doctor? E.g. Lump, cyst, rash, skin discolouration, inverted nipple, bleeding or discharge from the nipple or any other abnormality.

8 Have you had or been advised to have any medical investigation or consultation, advice, operation or treatment for any gynaecological disorder? HAVE YOU EVER HAD ANY OF THE FOLLOWING: Chest pain, irregular heart beat or raised cholesterol? Raised blood pressure? A lump, growth of any kind, a mole or freckle that has bled, become painful, changed colour or increased in size? Seizure, fits, fainting or blackouts? Numbness, loss of feeling or tingling of the limbs or face? Kidney, bladder or any other disorder of the genito-urinary system (including blood or protein in the urine and urinary tract infections and kidney failure/transplant)? Asthma? Bronchitis or any other respiratory (breathing) disorder? Any disorder of the digestive system, liver, stomach, pancreas or bowel (including gastric or duodenal ulcer, hepatitis, colitis, or

9 Crohn s Disease)? Any kind of medical attention for depression, anxiety, stress or nervous breakdown? Any arthritic or rheumatic complaint? If so, please give further details such as joints affected. Any disorder of the spine, neck or joints (including slipped disc, back or neck pain)? Gout? Any disorder of the eyes, including blurred or double vision or optic neuritis? (You can ignore sight problems corrected by glasses or contact lenses.) Any disorder of the ears? Blood disorder or anaemia? Have you had any recurrent insomnia or sleeping difficulty, or recurrent tiredness or fatigue in the last 5 years? Thyroid disorder? Any form of medical attention at a hospital, clinic as an inpatient or an outpatient or your GP, which has not already been disclosed in the last 5 years? Are you aware of any symptoms or complaints that you haven t

10 consulted a doctor or received treatment for? Do you have any more disclosures to give us about any medical investigation, test or consultation, advice, counselling, operation, medication or treatment that you ve had or been advised to have or are currently having, but haven t already mentioned? Are you currently taking prescribed drugs, medicines, tablets or any other treatment you have not already told us about? If yes please give details. Have you ever used drugs such as cannabis, ecstasy, cocaine, heroin or similar substances? If yes please give details. Have you ever been tested positive or been treated for any disease, which was transmitted sexually? If yes please give details. Within the last five years have you been exposed to the risk of HIV infection (this can be caught through unsafe sex, intravenous drug abuse, or blood transfusions or surgery undertaken outside the EU)? If yes please give details. Have you ever tested positive for HIV, Hepatitis

11 B or C or are you awaiting the results of such a test? If yes please give details. Have you anything to add to your declaration, which in your view, means that you are, or are not, at risk of HIV? If yes please give details Before they were 65, have any of your natural parents, brothers or sisters suffered from any of the following disorders: (If you answer yes to any of the below questions please give details of the family member, the nature of their condition and their age when the condition was diagnosed. In addition, if this was cancer please state which part of the body was affected.) Heart attack? Heart Disease? Angina? Cardiomyopathy? Stroke? Raised blood pressure? Kidney disease? Diabetes? Cancer?

12 Disorder of the nervous system? E.g. multiple sclerosis Polyposis of the colon? Hereditary disease? E.g. Huntingdon s disease, Alzheimer s or Parkinson s Are your parents alive? If so, what age are they? If not, what age did they pass away? Please give further details Have you ever had an application for Life, Critical Illness or Income Protection Cover refused, postponed, withdrawn or accepted only on special terms? If yes, please tell us the cover type, company, date, decision and reason given Do you have any existing Life, Critical Illness or Income Protection Cover policies? If yes for each cover please tell us The cover type, The total amount of cover, Whether you plan to cancel this policy once the new policy goes ahead.

13 Supplementary Sheet Name of condition When was this first diagnosed and your first symptoms? (dd/mm/yy) What treatment did you receive? What symptoms did you have? What was the last of the last major attack or symptoms? (dd/mm/yy) Have you been off work with this problem? If yes, when did you last return to work? (dd/mm/yy) Are you currently receiving any treatment? If yes, please tell us the treatment(s) Are you now fully recovered?

14 Raised Blood Pressure / Cholesterol Name of condition RAISED BLOOD PRESSURE RAISED CHOLESTEROL When was this first diagnosed? (dd/mm/yy) What treatment are you currently receiving? What medication are you taking Medication/No Treatment Name of medication: Dosage: How long have you been taking it for: Any side effects of medication/complications we should be aware of: Medication/No Treatment Name of medication: Dosage: How long have you been taking it for: Any side effects of medication/complications we should be aware of: What was your latest readings Are you under regular review with your GP/Specialist how often? Latest reading: Date taken: Latest reading: Date taken: LIST OF ANY MEDICATIONS YOU ARE TAKING AT PRESENT: NAME OF MEDICATION REASON FOR MEDICATION