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Section 1: Details of the person to be insured
Title *
Surname *
Forenames *
Address *
Postcode *
Contact telephone number *
Email *
Date of birth *
Sex *
Marital status *
Section 2: Details of the proposer, if different from the person to be insured
Title
Surname
Forenames
Address
Postcode
Details of insurable interest and reason for insurance or relationship to the person to be insured
 
Section 3: Insurance details.
Sum insured required *
Total sum insured under existing life insurance policies *
Commencement date required *
Are you currently effecting or intending to effect any other life insurance cover, or have you done so within the last 12 months? If so, please give details of companies, dates and sums insured.
 
Section 4: G.P. details
Name of doctor who currently holds your medical records *
Address *
Postcode *
Telephone *
If you have changed doctors within the last 3 months, please give the name of your previous doctor.
Address
Postcode
Telephone
Section 5: Occupation
Nature of business or occupation in which you are engaged (if more than one, please state all): *
Do your duties involve you in any way (other than clerical) with:
 1) the licenced trade or entertainment industry? YES *   NO *
If yes, please give full details
   2) working at heights, offshore, aviation (other than on scheduled flights), diving, or the fishing or mining industries, work requiring special safety precautions or any other activity which may be regarded as hazardous?
  YES *   NO *
If yes, please give full details
Does your job require a licence, e.g. driving?
  YES *   NO *
If yes, please give full details
Section 6: Smoking and alcohol details
Have you smoked any form of tobacco within the last 12 months?
  YES *   NO *
If yes, please give full details
Do you drink alcohol? YES *   NO *
If yes, please give full details
* Required fields.

Section 7: Personal details
Height  * Weight *
Has your weight changed recently? YES *   NO *
If yes, please give full details
When was your first positive HIV test result? *
Please give approximate date of infection, if known. *
Please give your CD4 count, if known. *
Please give your viral load, if known. *
What treatment are you taking? *
When did you start taking this treatment? *
Have you had any HIV-related illnesses or symptoms, such as pneumonia, diarrhoea, night sweats, etc?
  YES *   NO *
Nature of problem
Date
Have you EVER suffered from:
(a) any chest or lung disorder? YES *   NO *
If yes, please give full details
(b) anxiety, depression or other mental or nervous disorder? YES *   NO *
If yes, please give full details
(c) arthritis? YES *   NO *
If yes, please give full details
(d) epilepsy? YES *   NO *
If yes, please give full details
(e) any stomach or bowel complaint? YES *   NO *
If yes, please give full details
(f) diabetes, gout, kidney, liver, prostate or bladder problem, including hepatitis B or C? YES *   NO *
If yes, please give full details
(g) heart disease, rheumatic fever or chest pain? YES *   NO *
If yes, please give full details
(h) high blood pressure or stroke? YES *   NO *
If yes, please give full details
(i) lump, cyst or cancer? YES *   NO *
If yes, please give full details
Have you ever taken drugs other than over the counter or prescription medicine? YES *   NO *
If yes, please give full details
Do you anticipate travel outside your normal country of residence, Western Europe, North America or Australasia? YES *   NO *
If yes, please give full details
Do you engage in hazardous sports, such as aviation, motor sports, diving, etc.? YES *   NO *
If yes, please give full details
Have either of your parents or any brothers or sisters died from or suffered from heart disease, stroke, diabetes, cancer or a nervous disorder? YES *   NO *
If yes, please give full details
Click here to read the Section Important Notes, Medical Reports and Declaration.
 I've read the Section Important Notes, Medical Reports and Declaration and I agree.*
Click here to read our Provisions and Conditions.
 I've read the Provisions and Conditions and I agree.*
* Required fields.