What is the name and address of your current doctor? *

Phone Number

Providers may contact your GP for information to assist in underwriting your application. This can sometimes be done once your cover is live to ensure the correct terms have been offered to you. Do you consent to providers contacting your GP in this way? *

Marital Status *

Height is required

Weight is required

e.g, Size 10, 12, etc

e.g, 32, 34 etc

Have you Smoked, Vaped or used ANY nicotine products in the last 5 years? (inclusive of cigarettes, vapes, e-cigarettes and nicotine replacement products) *

1 Pint of beer = 2 Units, 1 Glass of wine (175ml) =2 Units, 1 Measure of spirit = 1 Unit

Alcohol units per week is required

Have you ever been advised to reduce your drinking or smoking on medical grounds? *

Have you ever injected non-prescription drugs, or have you ever taken drugs other than on medical advice? *

Do you take part, or intend to take part, in any of the following activities for leisure? You can ignore any one-off experience days. *

Have you EVER sought medical advice or received treatment for any of the following: *

Have you EVER sought medical advice or received treatment for any of the following: *

Have you EVER sought medical advice or received treatment for any of the following: *

Have you EVER sought medical advice or received treatment for any of the following: *

In the last 5 years, have you sought medical advice or received treatment for any of the following conditions: *

In the last 5 years, have you sought medical advice or received treatment for any of the following conditions: *

In the last 5 years, have you sought medical advice or received treatment for any of the following conditions: *

In the last 5 years, have you sought medical advice or received treatment for any of the following conditions: *

Have you ever sought medical advice or received treatment (including therapy) for any of the following: *

Other than consultations to do with conditions already disclosed, have you had a medical consultation in the last 12 months that has resulted in diagnosis and/or treatment? *

Not related to any of the conditions you have already disclosed, have you had any of the following in the last 5 years? *

Apart from what you have already disclosed, are you due to have any check-ups in the next 12 months in connection with any medical condition, or are you waiting for the result of any medical investigation? *

Have you ever undergone any surgical procedure outside the European Union or been a recipient of blood products outside the European Union *

Is there any other information about your medical history or current health that you'd like to make us aware of? *

If you have any hospital letters or reports relating to any of your medical disclosures, please upload them here. This may help speed up the underwriting process.

Have any of your natural parents, brothers or sisters, been DIAGNOSED with, or DIED from, any of the following illnesses, before the age of 65? *

If you have any hospital letters or reports relating to any investigations you have had for any hereditary conditions, please upload them here. This may help speed up the underwriting process.

Please provide the details of the bank account you wish to pay your monthly premiums from *

Life One Signature *

Date