CSC Financial - Health Questionnaire

During this application we will ask you personal questions about your lifestyle and health. We also share this information with insurers, who will use it to work out if they can offer you cover and at what price.

Thank you for taking the time to complete our Health Questionnaire.

01268 646113

[email protected]

csc-financial.co.uk

Important Customer Information

You can only apply if you are a UK resident – that does not include the Channel Islands or the Isle of Man.
The questions must only be answered by the person(s) to be insured.
You must answer the application questions truthfully and accurately. This is to help ensure insurers can pay valid claims.
Make sure you understand the questions we ask. If you do not, please contact us to clarify. Giving complete, accurate and up-to-date information, means your policy will be valid and any claim paid out promptly.
Around one in ten applications will be checked by obtaining information from your doctor, either before or shortly after your policy has started.

Your Medical Information

Insurers follow a strict confidentiality code about all medical information you give them, or which they get from any additional medical report. This is held securely and access is limited to authorised individuals who need to see it.

Genetic Testing

The only genetic test result which you will need to tell us about is one for Huntington's disease, and you will only need to tell us about this when the total life insurance you have or are buying is over £500,000.

I agree to my lifestyle and health information being used to continue the process and obtain indicative terms from insurers. I also agree to CSC Financial Ltd handling my data in line with CSC Financial's Privacy Policy.

Please provide your personal details

Title *

First Name *

Last Name *

Date of birth *

Your Telephone Number *

Your Email *

Gender at Birth *

How tall are you? Enter measurements in... *

Imperial

Metric

Height: (Feet/Inches) (Metres/Centimeters) *

How much do you weigh? Enter measurements in... *

Imperial

Metric

Weight: (Stone/lb) (Kilograms) *

Please detail any existing personal protection policies you currently have (life, critical illness or income protection policies) *

Please tell us about your family history

Have your birth parents, brothers, or sisters had any of these health conditions before they were 65? *

Heart attack, Angina, Stroke or Type 2 Diabetes

Cancer

Cardiomyopathy (primary disorder of the heart muscle)

Multiple sclerosis, Parkinson's disease or Alzheimer's disease

Muscular or Myotonic dystrophy, Huntington's disease or motor neurone disease

Polycystic kidney disease

Polyposis coli (Familial adenomatous)

Any other medical condition that runs within the family that you have been tested or advised to monitor

I don't know / No

If you have said yes to the above please provide further information.

Please tell us about your physical health

Have you ever had any of these health conditions? *

Cancer, Hodgkin lymphoma, Non-Hodgkin lymphoma, leukaemia or a melanoma or any other tumour

Diabetes or a heart condition, for example angina, heart attack, heart valve problem, heart surgery

A stroke, TIA, brain haemorrhage or damage or surgery to your brain

A cyst, growth, lump or tumour in your spine, brain or breast

Had any neurological condition or visual disturbance, for example epilepsy, multiple sclerosis, muscular dystrophy, cerebral palsy, motor neurone disease, Parkinson's disease, optic neuritis? (Please ignore long and short sightedness that's been corrected).

Any other disorder of the brain or nervous system

A positive test, or are you waiting on the results of a test for, HIV, AIDS or hepatitis B or C

Been admitted overnight to hospital or referred to a psychiatrist for mental illness, anorexia or bulimia?

No

If you have answered yes to any conditions, please provide dates you were diagnosed / discharged, and any treatments you received, or still receive.

To To help process your information, please be as specific as possible:

Date first diagnosed
How many episodes have you had in the last 5 years
How many days off work in the last 5 years have you had as a result
Details of your medication and treatment
Whether you're still receiving treatment/medication
Whether you have fully recovered

Please provide your Doctor's details

(the insurer may need to write to your GP for further information)

We may need to write to your GP for further information before a decision, please provide your GP Details

GP Surgery Name *

GP Address

GP Telephone Number

GP Name (if known)

Please detail anything else you feel may be relevant to your application

Do you have a current and up-to-date will? *

No

Yes

If 'No' - Would you look at making a will? *

No

Yes

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