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First Name

Last Name

Email

Date of birth *
Your Title Mr Mrs Miss Ms

Is your biological sex either Male Female Intersex

Marital Status Married Single Common Law Cohabiting Divorced Separated Widowed

Address line 1

Postcode

Telephone Number

Do you want to add a second applicant? No Yes

About the second applicant

Do you want to add a second applicant? Mr Mrs Miss Ms

Second Applicant's Gender Male Female

Second Applicant's Marital Status Married Single Common Law Cohabiting Divorced Separated Widowed

Second Applicant's Address line 1

Second Applicant's Postcode

Second Applicant's Smoker?
You are classed as a smoker if you have smoked or used any tobacco related products (including nicotine patches or e-cigarettes) within the last 12 months. Yes No

Second Applicant's First Name

Second Applicant's Last Name

Second Applicant's Date of birth

How much cover do you need?

How long do you need your policy to last?
This is the number of years you will be protected by the policy.

What type of cover do you need?
Level term policies pay out a fixed amount no matter when you claim during the policy term.
Decreasing term policies reduce the amount that's paid out over time. They are typically taken out to cover a repayment mortgage. Level term Decreasing term

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About you and your lifestyle

Please tell us some things about yourself:

How tall are you?

How much do you weigh?

What is your job?

Are you a smoker?
You are classed as a smoker if you have smoked or used any tobacco related products (including nicotine patches or e-cigarettes) within the last 12 months. Yes No

What is your average daily consumption of cigarettes over the last year?

What is your average daily consumption of cigars over the last year?

What is your average daily consumption of other tobacco (in grams) over the last year?

Which of these bests apply to you? I have never smoked I used to smoke but stopped over a year ago I've smoked in the last year but not every day I've vaped or used e-cigarettes in the last year I've used other nicotine replacement products in the last year

Have your birth parents, brothers, or sisters had any of these before they were 65? Heart attack, angina or stroke Cardiomyopathy Diabetes Bowel cancer or bowel polyps Any other cancer Muscular dystrophy, Huntington's disease or motor neurone disease Multiple sclerosis, Parkinson's disease or Alzheimer's disease Polycystic kidney disease I don't know No

Please tell us some general things about your lifestyle:

How many pints of beer, lager or cider do you drink per week?

How many glasses of wine do you drink per week?

How many measures of spirits do you drink per week?

How many other alcoholic drinks do you drink per week?

Have any of these applied to you? I've been advised by a medical professional to cut down or stop drinking alcohol I've been referred for alcohol or drug specialist support such as Alcoholics or Narcotics Anonymous I've used recreational drugs in the last 10 years No

Are you involved in any of these? Armed forces (including reserves) Scuba diving Private flying, gliding or parachuting Motor car or motorcycle sport Mountaineering or rock climbing Sailing at sea or powerboat racing No

Have any of these applied to you? I've been banned from driving or convicted of dangerous or careless driving in the last 5 years I ride a motorbike, scooter or moped on the road No

Have you lived, worked or travelled outside the UK or European Union in the last 5 years, or do you have any plans to do so in the next year?
You don't need to tell us about:
- Business trips of less than a week
- Holidays less than 30 days
Yes No

Do you have existing Life insurance or are you applying for any other Life insurance?* Yes No

Do you have existing Critical Illness insurance or are you applying for any other Critical Illness insurance? Yes No
About your health

Have you ever had:

Have you ever had any of these?* Please select all that apply: Cancer, cancer-in-situ, leukaemia, Hodgkin's disease or any other tumour Heart attack, irregular heart beat, cardiomyopathy, valve disorder or any other heart condition or heart surgery A stroke, TIA, brain haemorrhage or damage or surgery to your brain A stroke, TIA, brain haemorrhage or damage or surgery to your brain No

Have you ever had any of these?* Please select all that apply: Any mental health issue that's required a hospital or psychiatric referral or have you attempted or thought about suicide or self harm A positive test, or are you waiting on the results of a test for, HIV, AIDS or hepatitis B or C No

Your health in the last 5 years

In the last 5 years have you had any of these?* Please select all that apply: Raised blood pressure, cholesterol or chest pain Diabetes or raised blood sugar Depression, anxiety, stress, eating disorder or any other mental health issue Anaemia, blood clot or anything else affecting your blood A growth, lump or cyst No

In the last 5 years have you had any of these?* Please select all that apply: Asthma, sleep apnoea or anything else affecting your lungs or breathing Crohn's, colitis, IBS, or anything else affecting your stomach, bowel or digestive system Kidney stones, urinary infection or anything else affecting your kidneys, prostate, bladder or urine Anything affecting your liver or pancreas No

In the last 5 years have you had any of these?* Please select all that apply: Back pain, sciatica, whiplash or anything else affecting your back or neck Arthritis, gout or anything else affecting your bones, joints, ligaments, tendons or muscles Numbness, pins and needles, muscle weakness, tremor or difficulty with co-ordination No

In the last 5 years have you had any of these?* Please select all that apply: Tinnitus, labyrinthitis, or anything else affecting your ears, hearing or balance Impaired, blurred or double vision, optic neuritis or anything else affecting your eyes Chronic fatigue syndrome, ME, fibromyalgia or persistent tiredness No

Your health in the last 3 years

Have any of these applied to you in the last 3 years? You don't need to include things you've already told us about* Please select all that apply: I've taken or been prescribed treatment for 4 weeks or more I've been asked to attend a follow-up or regular reviews with a GP, hospital or clinic I've been advised to see a specialist or to have any tests, scans, investigations or counselling No

Your health in the last 3 months

Have you had any of these in the last 3 months, even if you haven't seen a doctor?* You don't need to include things you've already told us about Please select all that apply: Any lump, growth or hardening affecting either testicle Bleeding from the bowel or a change in bowel habit A cough lasting more than 3 weeks A fit or seizure A mole or skin blemish which has changed in appearance No
Additional Lifestyle Questions

Occupation:

Does your job involve any of the following duties or working environments? (select all that apply)* Please select all that apply: Working outside at heights above 12m (40ft) for more than 5 hours during a typical week Flying other than as a fare-paying passenger on commercial airlines General labouring or using heavy machinery Diving Fishing or merchant marine Oil or natural gas production Armed forces Armed forces reserves Mining, tunnelling or quarrying None of the above

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About the second applicant

About you and your lifestyle

Please tell us some things about yourself:

Please tell us some general things about your lifestyle:

About your health

Have you ever had:

Your health in the last 5 years

Your health in the last 3 years

Your health in the last 3 months

Additional Lifestyle Questions

Occupation:

More Ideas on saving money?

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