The obvious ones, please tell us who you are?*

Thank you. Can you please give your Date of Birth?*

Firstly, do you have any current life insurance policies?*

Do you have any current life insurance policies? *

Please give as much detail as possible about your current policies...*

Will you be keeping the current policies upon starting the new policy?*

Will you be keeping the current policies upon starting the new policy? *

Have you ever been declined life insurance?*

Have you ever been declined life insurance? *

Please give details as to why you have been declined cover previously*

What sick pay do you receive from work?*

What sick pay do you receive from work? *

Please give details*

We are now just going to ask some questions about your occupation

Firstly, what is your occupation?*

What type of industry is that?*

How many hours do you work in a typical week?*

What % of manual work do you do?*

What percentage of manual work do you do? *

What does your manual work consist of?*

Do you work underground, underwater, offshore, with firearms or explosives? or any other hazardous environment?*

Do you work underground, underwater, offshore, with firearms or explosives? or any other hazardous environment? *

Does your job involve working at heights over 40ft?*

Does your job involve working at heights over 40ft? *

How many business miles do you travel each year?*

Have you had any time off work in the last 2 years due to injury or illness?*

Have you had any time off work in the last 2 years due to injury or illness? *

Do you have a second job?*

Do you have a second job? *

Please give details about your 2nd job*

Thank you for your answers so far. The next section is about your hobbies / interests.

Do you take part in any hazardous sports or activities?*
E.g. Mountaineering, Diving, Flying, Horse Riding etc.

Do you take part in any hazardous sports or activities? *

*
E.g. Diving - is this confined spaces? how many meters do you go? are you certified?

*

Do you ride a motorcycle, scooter or moped on the roads? *

How many times per week do you exercise for 30 minutes or more?*

How many times per week do you exercise for 30 minutes or more? *

See, short and sweet. Next, we need to know more about you & your lifestyle...

*
Either in cm OR feet and inches

*
Please give in stone and pounds OR in KG

*
Male: please give UK waist size
Female: please give dress size if easier

Have you smoked or used any form of tobacco / nicotine replacement products in the last 12 months*

Have you smoked or used any form of tobacco / nicotine replacement products in the last 12 months? *

*


By this we mean pints or beer/lager, glasses of wine, measure of spirit

In an average week, how many alcoholic drinks would you consume? *

*

Have you ever been advised by a Doctor to reduce your alcohol intake? *

*

*
E.g. Cannabis, ecstasy, heroin, cocaine or anything not prescribed by a doctor

Have you ever taken recreational drugs? *

*


During the last 5 years, have you ever travelled abroad to another country for more than 30 days? *

*


Do you intend to travel out of the country for more than 30 days per time, in future? *

*


If you only know the name and town, please state

Do you consent for the insurer to request information from your GP, if required? *

Would you like to see a copy of that information before it is sent to the insurer? *

You're doing great.. the next sections are now more medically based
Don't worry, nothing too strenuous

Have you ever suffered from OR been tested for any of the following?*
- Any form of Cancer?
- Leukemia?
- Hodgkin's disease?
- Tumour?
- Lymphoma? or
- Melanoma?

Have you ever suffered from OR been tested for any of the following? (Cancer etc) *

Please give as much detail as you can about the selection you have just made*
Include details such as the diagnosis, date this occurred, any medication, time off work & any ongoing consultations

Have you ever suffered from OR been tested for any of the following?*
- Heart disorder?
- Heart attack?
- Angina?
- Cardiomyopathy?
- Heart murmur?

Have you ever suffered from OR been tested for any of the following? (Heart attack etc) *

Please give as much detail as you can about the selection you have just made*
Include details such as the diagnosis, date this occurred, any medication, time off work & any ongoing consultations

Have you ever suffered from OR been tested for any of the following?*
- Stroke?
- Brain haemorrhage?
- Transient ischaemic attack?
- Brain injury?
- Brain tumour?

Have you ever suffered from OR been tested for any of the following? (Stroke etc) *

Please give as much detail as you can about the selection you have just made*
Include details such as the diagnosis, date this occurred, any medication, time off work & any ongoing consultations

Have you ever suffered from OR been tested for any of the following?*
- Multiple sclerosis?
- Parkinson's disease?
- Paralysis?
- Alzheimer's disease?
- Dementia?
- Cerebral palsy?

Have you ever suffered from OR been tested for any of the following? (Parkinson's etc) *

Please give as much detail as you can about the selection you have just made*
Include details such as the diagnosis, date this occurred, any medication, time off work & any ongoing consultations

Have you ever suffered from OR been tested for any of the following?*
- Numbness?
- Loss of feeling?
- Tingling?
- Tremor?
- Temporary loss of muscle power?

Have you ever suffered from OR been tested for any of the following? (Numbness etc) *

Please give as much detail as you can about the selection you have just made*
Include details such as the diagnosis, date this occurred, any medication, time off work & any ongoing consultations

Have you ever suffered from OR been tested for any of the following?*
- Blindness?
- Blurred or disturbed vision?
E.g. Optic neuritis or glaucoma
(Only answer yes if this was not corrected by glasses/contact lenses)

Have you ever suffered from OR been tested for any of the following? (Blurred vision etc) *

Please give as much detail as you can about the selection you have just made*
Include details such as the diagnosis, date this occurred, any medication, time off work & any ongoing consultations

Have you ever suffered from OR been tested for any of the following?*
- Diabetes?
- Sugar in the urine?

Have you ever suffered from OR been tested for any of the following? (Diabetes vision etc) *

Please give as much detail as you can about the selection you have just made*
Include details such as the diagnosis, date this occurred, any medication, time off work & any ongoing consultations

Have you ever suffered from any mental illness that has required hospital treatment or referral to a psychiatrist?*

Have you ever suffered from any mental illness that has required hospital treatment or referral to a psychiatrist? *

Please give as much detail as you can about the selection you have just made*
Include details such as the diagnosis, date this occurred, any medication, time off work & any ongoing consultations

So far so good... the next section will ask questions of your medical history in the last 5 years

In the last 5 years, have you been diagnosed with or had symptoms of, any of the following?*
- A lump or growth of any kind, any mole or freckle that had bled, become painful, changed colour or increased in size?
- Chest pain, irregular heartbeat, raised blood pressure or raised cholesterol?
- Asthma?
- Breathlessness, bronchitis, sarcoidosis or any other lung disease?
- Epilepsy, dizziness or blackouts?
- Deafness or any ear problems?
- Arthritis, or any muscle, bone or joint disorder? (including sciatica, back, neck, shoulder or knee pain, RSI or gout)

In the last 5 years, have you been diagnosed with or had symptoms of, any of the following (Lumps, growths etc)? *

Please give further details to your answer. Give as much detail as possible.*

In the last 5 years, have you been diagnosed with or had symptoms of, any of the following?*
- Disorder of the digestive system, liver, stomach, pancreas or bowel, including ulcers, hepatitis, colitis or Crohn's disease?
- Blood disorder or anaemia?
- Thyroid disorder?
- Any kidney, bladder or other genitourinary disorder, including blood or protein in the urine, kidney cysts or multiple urinary tract infections?
- Stress, anxiety, depression, insomnia, chronic fatigue or any psychiatric or eating disorder?
- Any skin disorder or allergy?

In the last 5 years, have you been diagnosed with or had symptoms of, any of the following (Liver, stomach etc)? *

Please give further details to your answer. Give as much detail as possible.*

FEMALE ONLY:
In the last 5 years, have you been diagnosed with or had symptoms of any of the following?*
- Abnormal cervical smear, mammogram or had a biopsy of the breast, cervix or uterus?

FEMALE - In the last 5 years, have you been diagnosed with or had symptoms of, any of the following (Cervical smear etc)? *

Please give further details to your answer. Give as much detail as possible.*

MALE ONLY:
In the last 5 years, have you been diagnosed with or had symptoms of any of the following?*
- Prostate enlargement or raised PSA (prostate specific antigen)

MALE - In the last 5 years, have you been diagnosed with or had symptoms of, any of the following (Prostate etc)? *

Please give further details to your answer. Give as much detail as possible.*

Other than the medical conditions mentioned previously, have you...*
- Had or been advised to have any medical investigations, scans or blood tests?
- Received any form of medical attention at a hospital as an inpatient or outpatient?

Other than the medical conditions mentioned previously, have you... *

Please give further details to your answer. Give as much detail as possible.*

Nearly there now... The next section is all about your general health.

Are you currently experiencing any symptoms or disorders for which you haven't consulted a Doctor?*

Are you currently experiencing any symptoms or disorders for which you haven't consulted a Doctor? *

Please give details of your symptoms*

Are you currently taking drugs, medicine or tablets, or receiving any other treatment not already mentioned?*

Are you currently taking drugs, medicine or tablets, or receiving any other treatment not already mentioned? *

Please give details of what you are taking*

Are you currently awaiting a medical consultation or hospital appointment, or awaiting results of any tests?*

Are you currently awaiting a medical consultation or hospital appointment, or awaiting results of any tests? *

Please give details of appointments or tests taken*

Have you ever tested positive for HIV, hepatitis B or C or are you awaiting the results of a test?*

Have you ever tested positive for HIV, hepatitis B or C or are you awaiting the results of a test? *

Please give details of any tests and the results*

Within the last 5 years, have you been exposed to risk of HIV infection?*

Within the last 5 years, have you been exposed to risk of HIV infection? *

*

Within the last 5 years, have you tested positive or been treated for any disease which was transmitted sexually?*

Within the last 5 years, have you tested positive or been treated for any disease which was transmitted sexually? *

*

That is it.. you're all done. Final part is to ask about your Family History. By family, we mean any parents, brothers or sisters

Before aged 65, have any of your parents, brother or sisters been diagnosed with any of the following?*

Before aged 65, have any of your parents, brother or sisters been diagnosed with any of the following? *

*

Is your Father still alive?*

Is your Father still alive? *

*

*

Is your Mother still alive?*

Is your Mother still alive? *

*

*

Thank you. That's everything! Click the submit button below to finish.