LIFE TERM INSURANCE
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FULL NAME DOB HEIGHT WEIGHT
JOINT APPLICANT FULL NAME DOB HEIGHT WEIGHT
CONTACT PHONE NUMBER EMAIL ADDRESS
RELATIONSHIP BETWEEN APPLICANTS SELECT SPOUSE PARTNER CHILD BUSINESS PARTNER ARE ALL APPLICANTS UK CITIZENS YES NO
AMOUNT OF LIFE COVER REQUIRED SELECT £75000 £50000 £100000 £125000 £150000 £200000 £250000 £300000 £350000 £400000 £450000 £500000 £600000 £700000 £800000 £900000 YEARS TO AGE 70 5 10 15 20 25 30 TO AGE 65 WAIVER of PREMIUMS YES NO
HEALTH QUESTIONS APPLICANT ONE
SMOKER (in the last year) NO YES PIPE CIGARETTES HOW MANY PER DAY WEEKLY UNITS of ALCOHOL
HAVE YOU EVER BEEN REFUSED OR ACCEPTED ON SPECIAL TERMS FOR LIFE or HEALTH ASSURANCE.............................................................................. NO YES
HAVE YOU SUFFERED ANY DISABLING ILLNESS INCLUDING HIGH BLOOD PRESSURE, HEART, CIRCULATION, TUMOUR ETC.............................................. NO YES
ARE YOU TAKING ANY PRESCRIBED DRUGS or AWAITING THE RESULTS of ANY TEST or INVESTIGATION............................................................................ NO YES
IN THE LAST 5 YRS HAVE YOU BEEN INCAPACITATED for 10 CONSECUTIVE DAYS or BEEN AN IN PATIENT IN HOSPITAL or CLINIC..................................... NO YES
HAVE YOU EVER TESTED POSITIVE for HIV/AID or HEPATITIS B or C......................................................................................................................................... NO YES
DO YOU PARTAKE IN ANY HAZARDOUS ACTIVITIES IN YOUR WORK or LEISURE ACTIVITIES................................................................................................ NO YES
HAVE ANY of YOUR CLOSE FAMILY SUFFERED FROM HEART or CIRCULATION PROBLEMS BEFORE AGE 60.......................................................................... NO YES
HEALTH QUESTIONS APPLICANT TWO