ProposalForm

i) Gross yearly earnings:

j) Travel planned (days):

2. Policy Details

b) Coverage required:

(the total sum payable under the insurance in respect of any one claim in respect of any one person insured shall not exceed in all the largest sum insured under any one of the items contained in the scale of benefits)

3. Other Insurances

PROPOSED INSURED’S DETAILS (to be completed by ALL Proposed Insureds)

a) Are you currently insured against accident and/or illness:

Yes

If ‘Yes’, please give details including capital sum and weekly or monthly benefit:

b) Have you ever had any insurance deferred or cancelled, or have you ever had a proposal for disability insurance declined or accepted with any special conditions or exclusions imposed?

Yes

If ‘Yes’, please give details:

4. Insured’s Activities

PROPOSED INSURED’S DETAILS (to be completed by ALL Proposed Insureds)

a) Do you participate in any of the following activities; Winter Sports, Water or Underwater Sports, Horse Riding, Parachuting, Rock Climbing or Mountaineering, Motorsports or any other similar activities?

Yes

If ‘Yes’, please give details:

b) Do you participate in Rugby and/or Football or any other similar occupation, sport, pastime or activity on a regular, competitive basis?

Yes

If ‘Yes’, please give details:

c) Do you intend to fly as a passenger other than on a scheduled airline?

Yes

If ‘Yes’, please give details:

5. Personal Medical History

a) Are you currently free of injury, illness or discomfort and physically able to perform all of the duties required of your job as stated in Section 1 of the Proposal Form?

Yes

If ‘No’ please give details:

b) Are you currently taking any medication or drugs, whether or not prescribed by a doctor, or are you receiving any treatment?

Yes

If ‘Yes’, please give details:

c) Have you consulted any doctor, hospital or clinic within the last 3 years?

Yes

If ‘Yes’, please give details:

d) In the last 3 years, have you suffered from any condition that has required medication for a period that has lasted more than for 4 weeks?

Yes

If ‘Yes’, please give details:

e) Have you ever been referred by a medical professional to take medical tests or screening at a medical facility?

Yes

If ‘Yes’, please give details:

a) Defect in your sight, hearing or any other senses?

Yes

b) Asthma, bronchitis, respitory, breathlessness or any chest or lung disorder?

Yes

c) Heart disease, heart attack, angina, heart defect, rheumatic fever or chest pain?

Yes

d) High blood pressure, varicose veins, any other circulatory disorder or rheumatic fever?

Yes

e) Stroke, brain haemorrhage or transient ischaemic attack?

Yes

f) Diabetes, underactive or overactive thyroid or any other hormonal disorder?

Yes

g) Urinary or digestive system disorders?

Yes

h) Liver, kidneys or any other vital organs not previously mentioned?

Yes

i) Spinal disorders or any rheumatic or arthritic condition?

Yes

j) Nervous system, loss of consciousness, epilepsy, seizures or convulsions?

Yes

k) Clinical depression, anxiety or any other mental conditions?

Yes

l) Blood disorder, anaemia or blood clotting disorder?

Yes

m) Cancer, hodgkin’s disease, lymphoma, leukaemia, brain tumour or spinal tumour?

Yes

n) Paralysis whether complete or partial, regardless of length of time or duration?

Yes

o) HIV/AIDS or Hepatitis B or C, or have been tested for any other sexually transmitted disease?

Yes

p) Muscular disorder, hernia or hemorrhoids?

Yes

If ‘Yes’ to any of the above, please give details including dates (dd/mm/yyyy):

q) Have you ever undergone hospitalisation, surgery, or received treatment as a result of sickness, disease or injury ?

Yes

If ‘Yes’ please give details:

r) Please give details of any family history of any of the conditions mentioned above, and relationship (i.e. mother, father, brother, etc.):

Yes

s) In the last 12 months, have you smoked or used any form of tobacco products?

Yes

If yes, how frequently?

If ‘Yes’ please give details:

t) Do you drink alcohol?

Yes

If yes, how many units per week?

If ‘Yes’ please give details:

u) Have you ever used drugs, other than those prescribed by a doctor or obtained over the counter? E.g. recreations drugs such as heroin, cocaine, ecstasy, etc.?

Yes

If ‘Yes’ please give details:

Please use this area of the proposal form to give complete details of any answers to questions in the Personal Medical History section.

Declaration

I/we declare that I/we have made a fair presentation of the risk, by disclosing all material matters which I/we know or ought to know or, failing that, by giving the Insurer sufficient information to put a prudent insurer on notice that it needs to make further enquiries in order to reveal material circumstances.

1. Insured Person’s Details

PROPOSED INSURED’S DETAILS (to be completed by ALL Proposed Insureds)

2. Policy Details

3. Other Insurances

PROPOSED INSURED’S DETAILS (to be completed by ALL Proposed Insureds)

4. Insured’s Activities

PROPOSED INSURED’S DETAILS (to be completed by ALL Proposed Insureds)

5. Personal Medical History

Declaration