PLEASE ANSWER ALL QUESTIONS UNLESS NOT APPLICABLE, OTHERWISE
THE INSURERS WILL NOT BE ABLE TO PROVIDE YOU WITH A QUOTE. THANK YOU.
ILLUSTRATION OPTIONS
Do you want single or joint cover?
Please select
Single cover
Joint cover
PERSONAL DETAILS
First life assured
Second life assured
Title
Mr
Mrs
Ms
Dr
Rev
N/A
Mr
Mrs
Ms
Dr
Rev
If other, please specify
First name
Last name
Gender
Male
Female
N/A
Male
Female
Date of birth (dd/mm/yy)
Nationality
PLEASE SELECT
Afghan
Albanian
Algerian
American
American Samoan
Andorran
Angolan
Anguillan
Antiguan, Barbudan
Argentinean
Armenian
Aruban
Australian
Austrian
Azerbaijani
Bahamian
Bahraini
Bangladeshi
Barbadian
Belarusian
Belgian
Belizean
Beninese
Bermudian
Bhutanese
Bolivian
Bosnian, Herzegovinian
Brazilian
British
British Virgin Islander
Bruneian
Bulgarian
Burkinabe
Burundian
Cambodian
Cameroonian
Canadian
Cape Verdean
Caymanian
Central African
Chadian
Channel Islander
Channel Islander
Chilean
Chinese
Christmas Islander
Cocos Islander
Colombian
Comoran
Congolese
Congolese
Cook Islander
Costa Rican
Croatian
Cuban
Cypriot
Czech
Danish
Djibouti
Dominican
Dominican
Dutch
Dutch Antillean
Dutch, French
Ecuadorian
Egyptian
Emirati
Equatorial Guinean
Eritrean
Estonian
Ethiopian
Falkland Islander
Faroese
Fijian
Filipino
Finnish
French
French Guianese
French Polynesian
Gabonese
Gambian
Georgian
German
Ghanaian
Gibraltarian
Greek
Greenlander
Grenadian
Guadeloupian
Guamanian
Guatemalan
Guinea-Bissauan
Guinean
Guyanese
Haitian
Honduran
Hong Konger
Hungarian
Icelander
I-Kiribati
Indian
Indonesian
Iranian
Iraqi
Irish
Israeli
Italian
Ivorian
Jamaican
Japanese
Jordanian
Kazakhstani
Kenyan
Kittitian; Nevisian
Korean
Korean
Kuwaiti
Kyrgyzstani
Laotian
Latvian
Lebanese
Liberian
Libyan
Liechtensteiner
Lithuanian
Luxembourger
Macanese
Macedonian
Mahorais
Malagasy
Malawian
Malaysian
Maldivian
Malian
Maltese
Manx
Marshallese
Martiniquais
Mauritanian
Mauritian
Mexican
Micronesian
Moldovan
Monegasque
Mongolian
Montenegrin
Montserratian
Moroccan
Mosotho
Motswana
Mozambican
Myanmarese
Namibian
Nauruan
Nepalese
New Caledonian
New Zealander
Nicaraguan
Nigerian
Nigerien
Niuean
Ni-Vanuatu
Norfolk Islander
Norwegian
Omani
Pakistani
Palauan
Palestinian
Panamanian
Papua New Guinean
Paraguayan
Peruvian
Pitcairn Islander
Polish
Portuguese
Puerto Rican
Qatari
Reunionese
Romanian
Russian
Rwandan
Sahrawi
Saint Helenian
Saint Lucian
Saint Vincentian
Salvadoran
Sammarinese
Samoan
Sao Tomean
Saudi Arabian
Senegalese
Serbian
Seychellois
Sierra Leonean
Singaporean
Slovakian
Slovenian
Solomon Islander
Somali
South African
Spanish
Sri Lankan
Sudanese
Surinamese
Swazi
Swedish
Swiss
Syrian
Taiwanese
Tajik
Tanzanian
Thai
Timorese
Togolese
Tokelauan
Tongan
Trinidadian
Tunisian
Turkish
Turkmen
Tuvaluan
Ugandan
Ukrainian
Uruguayan
Uzbek
Vatican
Venezuelan
Vietnamese
Virgin Islander
Wallisian, Futunan
Yemeni
Zambian
Zimbabwean
Please select
Afghan
Albanian
Algerian
American
American Samoan
Andorran
Angolan
Anguillan
Antiguan, Barbudan
Argentinean
Armenian
Aruban
Australian
Austrian
Azerbaijani
Bahamian
Bahraini
Bangladeshi
Barbadian
Belarusian
Belgian
Belizean
Beninese
Bermudian
Bhutanese
Bolivian
Bosnian, Herzegovinian
Brazilian
British
British Virgin Islander
Bruneian
Bulgarian
Burkinabe
Burundian
Cambodian
Cameroonian
Canadian
Cape Verdean
Caymanian
Central African
Chadian
Channel Islander
Channel Islander
Chilean
Chinese
Christmas Islander
Cocos Islander
Colombian
Comoran
Congolese
Congolese
Cook Islander
Costa Rican
Croatian
Cuban
Cypriot
Czech
Danish
Djibouti
Dominican
Dominican
Dutch
Dutch Antillean
Dutch, French
Ecuadorian
Egyptian
Emirati
Equatorial Guinean
Eritrean
Estonian
Ethiopian
Falkland Islander
Faroese
Fijian
Filipino
Finnish
French
French Guianese
French Polynesian
Gabonese
Gambian
Georgian
German
Ghanaian
Gibraltarian
Greek
Greenlander
Grenadian
Guadeloupian
Guamanian
Guatemalan
Guinea-Bissauan
Guinean
Guyanese
Haitian
Honduran
Hong Konger
Hungarian
Icelander
I-Kiribati
Indian
Indonesian
Iranian
Iraqi
Irish
Israeli
Italian
Ivorian
Jamaican
Japanese
Jordanian
Kazakhstani
Kenyan
Kittitian; Nevisian
Korean
Korean
Kuwaiti
Kyrgyzstani
Laotian
Latvian
Lebanese
Liberian
Libyan
Liechtensteiner
Lithuanian
Luxembourger
Macanese
Macedonian
Mahorais
Malagasy
Malawian
Malaysian
Maldivian
Malian
Maltese
Manx
Marshallese
Martiniquais
Mauritanian
Mauritian
Mexican
Micronesian
Moldovan
Monegasque
Mongolian
Montenegrin
Montserratian
Moroccan
Mosotho
Motswana
Mozambican
Myanmarese
Namibian
Nauruan
Nepalese
New Caledonian
New Zealander
Nicaraguan
Nigerian
Nigerien
Niuean
Ni-Vanuatu
Norfolk Islander
Norwegian
Omani
Pakistani
Palauan
Palestinian
Panamanian
Papua New Guinean
Paraguayan
Peruvian
Pitcairn Islander
Polish
Portuguese
Puerto Rican
Qatari
Reunionese
Romanian
Russian
Rwandan
Sahrawi
Saint Helenian
Saint Lucian
Saint Vincentian
Salvadoran
Sammarinese
Samoan
Sao Tomean
Saudi Arabian
Senegalese
Serbian
Seychellois
Sierra Leonean
Singaporean
Slovakian
Slovenian
Solomon Islander
Somali
South African
Spanish
Sri Lankan
Sudanese
Surinamese
Swazi
Swedish
Swiss
Syrian
Taiwanese
Tajik
Tanzanian
Thai
Timorese
Togolese
Tokelauan
Tongan
Trinidadian
Tunisian
Turkish
Turkmen
Tuvaluan
Ugandan
Ukrainian
Uruguayan
Uzbek
Vatican
Venezuelan
Vietnamese
Virgin Islander
Wallisian, Futunan
Yemeni
Zambian
Zimbabwean
Are you a UK resident?
Please select
Yes
No
N/A
Yes
No
Full address
Telephone number
E mail
Do you drink alcohol?
Please select
Yes
No
N/A
Yes
No
If so, what is your weekly consumption? (a unit of alcohol is equivalent to half a pint of normal strength beer, lager or cider, one standard glass of wine or a single measure of spirit)
units
units
Have you been advised by a member of the medical profession to reduce your intake?
Yes
No
Yes
No
Have you smoked or used any tobacco or nicotine product in the last 12 months? Please note, the insurers may require a test to confirm your non-smoking status.
Yes
No
N/A
Yes
No
If yes, what is your average weekly consumption? (eg amount and type: 100 cigarettes, 4ozs pipe tobacco, 20 cigars)
What is your height?
ft
ins OR
cms
ft
ins OR
cms
What is your weight?
st
ozs OR
kgs
st
ozs OR
kgs
PLAN DETAILS
Type of policy required
Please select
Whole of life
Level term assurance
Family Income Benefit
Gift Inter Vivos
You must tell us how much you want the life assurance policy to cover you for or the amount of monthly premium you wish to pay, so one of the next two questions must be answered:
Sum assured or annual income if FIB
OR monthly premium payable
Policy term (maximum is currently 10 years)
years
years
If joint life, should the sum assured be payable upon:
Please select
First death (not available on whole of life)
Second death (only available on whole of life
Premium payment payable
Please select
Monthly
Annually
Single (Whole of Life or GIV only)
PREVIOUS COVER
Has any proposal for life cover been declined or postponed?
Please select
Yes
No
N/A
Yes
No
If yes, please give us the date
Company that declined/postponed cover
Reason why (if known)
If postponed, for how long?
Are there any proposals for life assurance benefits currently being made to other insurers?
Please select
Yes
No
N/A
Yes
No
If so, please provide details
HAZARDOUS ACTIVITES
Sports/pastimes - please provide full details if you take part in any hazardous sports/passtimes
What is your current occupation?
If you work at heights, underground, underwater or offshore, please provide full details
Are you unable to work for medical reasons?
Please select
Yes
No
N/A
Yes
No
Have your parents, brothers or sisters, before age 65, died or suffered from heart disease, stroke, high blood pressure, diabetes, kidney disease, cancer, multiple sclerosis, paralysis or any hereditary disorder?
Please select
Yes
No
N/A
Yes
No
If so, please indicate the age of the relative when they first suffered the condition and details of the condition itself including, for cancer, the part of the body affected.
DETAILS ABOUT HIV HEALTH CONDITION
When was your first positive HIV test result?
Date of Infection (if known)
Have you had any HIV-related illnesses or symptoms, such as pneumonia, diarrhoea, night sweats, etc.?
Yes
No
N/A
Yes
No
Please provide full details
Please give your latest CD4 count
Please give your latest viral load count
What treatments or investigations have you had, including dates?
What medication are you currently taking, including its name and quantity?
Have you ever taken drugs, other than “over the counter” medicine or as prescribed by a qualified doctor?
Yes
No
N/A
Yes
No
Have you ever suffered from hepatitis B or C?
Yes
No
N/A
Yes
No
If you have any other health conditions, please give details below
OTHER HEALTH CONDITION 1
Name of condition, illness or injury
Date diagnosed
Treatments, including dates
Medication, including name and quantity
OTHER HEALTH CONDITION 2
Name of condition, illness or injury
Date diagnosed
Treatments, including dates
Medication, including name and quantity
OTHER HEALTH CONDITION 3
Name of condition, illness or injury
Date diagnosed
Treatments, including dates
Medication, including name and quantity
OTHER HEALTH CONDITION 4
Name of condition, illness or injury
Date diagnosed
Treatments, including dates
Medication, including name and quantity
FURTHER INFORMATION
Please give us any other information you think might be relevant