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Insurance application

Date of Birth
Have you smoked in the last 12 months or do you currently use other nicotine or replacement products? YesNo
If yes, what do you smoke/use (cigarettes, pipe, cigars, replacement products) & how many per day/grams of tobacco per day for pipe smokers?
Do you drink alcohol? YesNo
If yes, what do you normally drink and how many units do you drink each week? (1 unit = e.g. ½ pint of beer or small glass of wine)
GP Details:
Have you (in the last 5 years) travelled, lived or worked outside of Europe, USA, Canada, Australia or New Zealand and/or do you intend (in the next 2 years) to travel, live or work outside the UK for more than 30 days?
YesNo
Do you, or are you likely to take part in any of the following activities: Flying (other than as a fare-paying passenger or cabin crew), potholing, motor car sport, motor cycle sport, powerboat racing, sky diving, parachuting, hang gliding, diving, rock climbing, caving, mountaineering, sailing, any other extreme sport?
YesNo
Have you ridden a motorcycle or moped in the last 12mths?
YesNo
Have you ever been banned from driving?
YesNo
Have you ever tested positive for HIV/ AIDS, Hepatitis B or C or are you waiting the results of such a test?
YesNo
Have you ever used or injected drugs that were not prescribed for you, e.g. cocaine, heroin, cannabis, ecstasy?
YesNo
Do you currently have or have you ever had or any of the following?
Heart attack, angina, any heart defect or murmur, heart valve problem, cardiomyopathy or heart surgery?
YesNo
A stroke, mini stroke, transient ischaemic attack (TIA), brain haemorrhage or surgery to your blood vessels?
YesNo
Any other disease or disorder of the arteries, including disease in the legs or of the aorta?
YesNo
Any form of cancer, Hodgkin or non-Hodgkin lymphoma, brain or spinal tumour, spinal cyst, growth or tumour, melanoma or leukaemia?
YesNo
Any form of neurological disorder, multiple sclerosis, visual disturbances e.g. epilepsy, muscular dystrophy, cerebral palsy, motor neurone disease, Parkinson’s disease, retrobulbar or optic neuritis, paralysis or any other disorder of the central nervous system?
YesNo
Diabetes or sugar in the urine?
YesNo
For Women only: Any gynaecological disorder, e.g. abnormal smear, fibroids?
YesNo
Mental illness that has required hospital treatment or referral to a psychiatrist e.g. anorexia or bulimia?
YesNo
Do you currently have, or in the last 5 years have you had any of the following (please answer yes even if you have not yet sought medical advice):
A lump, growth, polyp or tumour of any kind, or any mole or freckle that has bled, become painful, changed colour or increased in size?
YesNo
Chest pain, palpitations or irregular heartbeat, paralysis, numbness, persistent tingling or pins and needles, tremor or facial pain other than dental pain, memory loss, dizziness or balance problems?
YesNo
Raised blood pressure or cholesterol, or condition affecting your blood or blood vessels, e.g. anaemia, excess sugar in the blood, blood clot, deep vein thrombosis?
YesNo
Any condition affecting your kidney, bladder or prostate, e.g. blood or protein in the urine, kidney or bladder stones?
YesNo
Any condition affecting your stomach, oesophagus or bowel, e.g. Crohn’s disease, ulcerative colitis?
YesNo
Any condition affecting your gall bladder, liver or pancreas, e.g. hepatitis or fatty liver?
YesNo
Lupus, fibromyalgia, gout or any type of arthritis, neck, back, spine or joint trouble, e.g. osteo or rheumatoid arthritis, slipped disc, rheumatism or sciatica?
YesNo
Anxiety, depression, or any form of nervous or mental illness that has required counselling or for which you have been prescribed tranquilisers or anti-depressants?
YesNo
Any form of numbness, tingling, dizziness, balance problems, persistent pins and needles or facial pain (ignore dental pain)?
YesNo
Been referred to or had a scan or other investigation of the heart, brain or nervous system e.g. angiogram, ECG, MRI, CT Scan, biopsy?
YesNo
Asthma, bronchitis, emphysema, sleep apnoea, sarcoidosis or any other problem, disease or abnormality affecting our lungs?
YesNo
Any condition affecting your eyes or vision, not corrected by spectacles, lenses or laser treatment, e.g. cataract, blindness?
YesNo
Any condition affecting your ears or hearing, e.g. Meniere’s disease, deafness, tinnitus, labyrinthitis?
YesNo
Tested positive, or been treated for any sexually transmitted infections or are you awaiting the results of such tests?
YesNo
Weight loss treatment including surgery, e.g. gastric banding or bypass, any eating disorder, chronic fatigue or Persistent tiredness?
YesNo
Are you currently awaiting the results of any tests?
YesNo
Apart from anything you’ve already indicated, in the last 12 months, have you:
Had any medical conditions illness or injury that you’ve received treatment for over a continuous period of 4 weeks or more?
YesNo
Had any other illness, injury or disability, that’s kept you off work for 2 continuous weeks or more e.g. stress, tension, pressure of work, headaches or trapped nerve?
YesNo
Apart from anything you’ve already indicated, in the last 3 months:
Do you have any symptoms or medical condition that your GP or nurse told you to see them about?
YesNo
Have you had any of the following symptoms: unexplained bleeding, weight loss, lump or growth, mole or freckle that’s bled or changed in appearance, a cough that’s lasted for 3 weeks or more, any other symptom that you may see a health professional for the first time during the next 4 weeks?
YesNo
Before the age of 60, have any of your natural parents or siblings died or been diagnosed with any of the conditions mentioned above?
YesNo
Please supply bank details to allow the setup of the Direct Debit:
What date would you prefer the Direct Debit to come off your account?
We provide the e-mail address you give us which the lender will use for initial confirmation of policy. However, if the Insurance provider would like to get in touch with you in the future, how do you want them to contact you?
PhoneE-mailPostTextPrefer no ongoing contact