Insurance Details Form Health and Activities Please provide us with the details we need to consider your insurance needs. Step 1 Your details Are there two applicants? Choosing "yes" adds Applicant Two's own set of questions after Applicant One's are complete. Yes, two applicants No, one applicant Applicant One First name(s) Surname Email address Next Applicant One: Doctors details Doctor's name Telephone Postcode lookup Find Address Select an address Address line 1 Address line 2 Address line 3 Town Postcode Previous Next Applicant One: Height and weight You may enter metric or imperial figures. Your height Your weight Your waist measurement In the last 6 months has your weight decreased by more than 3kg/7lbs through non-diet loss? Yes No Details Previous Next Applicant One: Occupation How many hours do you work each week? Hours worked Please indicate the percentage of your time at work spent in each of the following areas. Manual work (%) Driving (%) Working at height (%) Previous Next Applicant One: Activities Do you regularly ride a motorcycle? Yes No Details Are you a member of the armed forces, TA, or reservists? Yes No Details Previous Next Applicant One: Smoking If you have used tobacco products in the past 12 months please enter weekly intake below. Cigarettes per week Cigars per week Pipe tobacco (g) per week Vapes per week If non-smoker, have you ever smoked? Yes No Details Previous Next Applicant One: Alcohol Please confirm your weekly intake of alcohol below. If none, enter zero. Units per week Have you ever been given, or sought, advice from any medical practitioner regarding your consumption of alcohol? Yes No Details Previous Next Applicant One: Hazardous sports Please confirm if you are involved in hazardous sports such as rock climbing or pot holing. If none, enter none. I take part in Previous Next Applicant One: Health section If you answer yes to any of the questions below, please give full details including dates, durations, and test results where relevant. Cancer, leukaemia, Hodgkin's disease, lymphoma, brain or spinal tumour? Yes No Details Heart disease including angina, heart attack, or any other disorder of the heart? Yes No Details Stroke, brain haemorrhage, permanent brain injury through accident? Yes No Details Multiple sclerosis, Parkinson's disease, paralysis, epilepsy, Alzheimer's disease, dementia, or cerebral palsy? Yes No Details Any disorder of the central nervous system not already mentioned? Yes No Details Disease or disorder of the arteries, including legs and aorta? Yes No Details Diabetes or sugar in the urine? Yes No Details Mental illness requiring hospital treatment or referral to a psychiatrist? Yes No Details Any other consultation, treatment, or investigation of any kind? Yes No Details Previous Next Applicant One: Family history Have you, or any of your natural parents, brothers, or sisters, suffered or died before age 65 from hypertension, heart or circulatory disorders, stroke, cancer, tumours or growths, diabetes or kidney disease, multiple sclerosis, paralysis, or any other disorder of the brain or nervous system? Family history details? Yes No Details Who? Condition? Age at onset? Age died, if applicable? More family history? Yes No Who? Condition? Age at onset? Age died, if applicable? Previous Next Applicant One: Medication Are you suffering from any illness, impairment, or disability not already mentioned above, or are you taking any medication or drugs? Yes No Details Previous Next Applicant One: STD and HIV This includes HIV, Hepatitis B or C, exposure to HIV infection, sexually transmitted disease, or non-prescription drug use. Any STD, HIV, hepatitis, or non-prescription drug disclosures? Yes No Details Previous Next Applicant One: Overseas travel Have you, within the past 5 years, or do you intend to travel or live outside of the UK other than for normal holidays? Yes No Details Previous Next Applicant Two: Personal details First name(s) Surname Previous Next Applicant Two: Doctors details Doctor's name Telephone Postcode lookup Find Address Select an address Address line 1 Address line 2 Address line 3 Town Postcode Previous Next Applicant Two: Height and weight You may enter metric or imperial figures. Your height Your weight Your waist measurement In the last 6 months has your weight decreased by more than 3kg/7lbs through non-diet loss? Yes No Details Previous Next Applicant Two: Occupation How many hours do you work each week? Hours worked Please indicate the percentage of your time at work spent in each of the following areas. Manual work (%) Driving (%) Working at height (%) Previous Next Applicant Two: Activities Do you regularly ride a motorcycle? Yes No Details Are you a member of the armed forces, TA, or reservists? Yes No Details Previous Next Applicant Two: Smoking If you have used tobacco products in the past 12 months please enter weekly intake below. Cigarettes per week Cigars per week Pipe tobacco (g) per week Vapes per week If non-smoker, have you ever smoked? Yes No Details Previous Next Applicant Two: Alcohol Please confirm your weekly intake of alcohol below. If none, enter zero. Units per week Have you ever been given, or sought, advice from any medical practitioner regarding your consumption of alcohol? Yes No Details Previous Next Applicant Two: Hazardous sports Please confirm if you are involved in hazardous sports such as rock climbing or pot holing. If none, enter none. I take part in Previous Next Applicant Two: Health section If you answer yes to any of the questions below, please give full details including dates, durations, and test results where relevant. Cancer, leukaemia, Hodgkin's disease, lymphoma, brain or spinal tumour? Yes No Details Heart disease including angina, heart attack, or any other disorder of the heart? Yes No Details Stroke, brain haemorrhage, permanent brain injury through accident? Yes No Details Multiple sclerosis, Parkinson's disease, paralysis, epilepsy, Alzheimer's disease, dementia, or cerebral palsy? Yes No Details Any disorder of the central nervous system not already mentioned? Yes No Details Disease or disorder of the arteries, including legs and aorta? Yes No Details Diabetes or sugar in the urine? Yes No Details Mental illness requiring hospital treatment or referral to a psychiatrist? Yes No Details Any other consultation, treatment, or investigation of any kind? Yes No Details Previous Next Applicant Two: Family history Have you, or any of your natural parents, brothers, or sisters, suffered or died before age 65 from hypertension, heart or circulatory disorders, stroke, cancer, tumours or growths, diabetes or kidney disease, multiple sclerosis, paralysis, or any other disorder of the brain or nervous system? Family history details? Yes No Details Who? Condition? Age at onset? Age died, if applicable? More family history? Yes No Who? Condition? Age at onset? Age died, if applicable? Previous Next Applicant Two: Medication Are you suffering from any illness, impairment, or disability not already mentioned above, or are you taking any medication or drugs? Yes No Details Previous Next Applicant Two: STD and HIV This includes HIV, Hepatitis B or C, exposure to HIV infection, sexually transmitted disease, or non-prescription drug use. Any STD, HIV, hepatitis, or non-prescription drug disclosures? Yes No Details Previous Next Applicant Two: Overseas travel Have you, within the past 5 years, or do you intend to travel or live outside of the UK other than for normal holidays? Yes No Details Previous Next Additional information If there is anything else you believe your insurer should be aware of, please enter details below. Details Please confirm your understanding We will keep your data securely on file in line with our privacy policy. Data will not be passed to third parties without your permission and you may withdraw your permission for us to hold your data at any time. Please confirm that we may keep your data securely on file and use it to assist you. We may contact you by telephone, email, or post, to keep you updated on the progress of your enquiry or application. Please confirm that we have your permission to contact you. Previous Submit ✓ Thank you Your Protection Information has been received. One of our team is now dealing with your case and we will keep you informed on progress. If you need to contact us sooner please call our Team on 020 8979 9684
