Insurance details form

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

Applicant One: Doctors details

Doctor's name

Telephone

Postcode lookup

Address line 1

Address line 2

Address line 3

Town

Postcode

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

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 (%)

Applicant One: Activities

Do you regularly ride a motorcycle?

Yes No

Are you a member of the armed forces, TA, or reservists?

Yes No

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

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

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

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

Who?

Condition?

Age at onset?

Age died, if applicable?

More family history?

Yes No

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

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

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

Applicant Two: Personal details

First name(s)

Surname

Applicant Two: Doctors details

Doctor's name

Telephone

Postcode lookup

Address line 1

Address line 2

Address line 3

Town

Postcode

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

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 (%)

Applicant Two: Activities

Do you regularly ride a motorcycle?

Yes No

Are you a member of the armed forces, TA, or reservists?

Yes No

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

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

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

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

Who?

Condition?

Age at onset?

Age died, if applicable?

More family history?

Yes No

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

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

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

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.

Insurance Details Form

Health and Activities

Your details

Applicant One

Applicant One: Doctors details

Applicant One: Height and weight

Applicant One: Occupation

Applicant One: Activities

Applicant One: Smoking

Applicant One: Alcohol

Applicant One: Hazardous sports

Applicant One: Health section

Applicant One: Family history

Applicant One: Medication

Applicant One: STD and HIV

Applicant One: Overseas travel

Applicant Two: Personal details

Applicant Two: Doctors details

Applicant Two: Height and weight

Applicant Two: Occupation

Applicant Two: Activities

Applicant Two: Smoking

Applicant Two: Alcohol

Applicant Two: Hazardous sports

Applicant Two: Health section

Applicant Two: Family history

Applicant Two: Medication

Applicant Two: STD and HIV

Applicant Two: Overseas travel

Additional information

Please confirm your understanding

Thank you