Let's Secure Your Financial Future from Day One

csc-financial.co.uk

01268 646113

Important Customer Information

Thank you for taking the next step with us.

Now that we've had our initial meeting, we’d like to gather a few important details about your health. This short form helps us build a full picture of your circumstances so we can provide personalised protection recommendations alongside your mortgage — not just to help you buy your home, but to help you keep it, no matter what life throws your way.

By understanding your health background, we can ensure any protection policies we suggest — like income protection, life cover, or critical illness cover — are realistic, relevant, and reliable. It means less chance of surprises down the line and more confidence that your mortgage and lifestyle are secure, even if your health takes an unexpected turn.

Please take a few minutes to answer the questions honestly and in as much detail as you can. If you're unsure about anything, just give us your best estimate — we’re always here to help if you need clarification.

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 *

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 tell us about your lifestyle

Please choose the best description of your smoking status *

If applicable, when did you last smoke?

If applicable, how many did / do you smoke per day?

Do you consume Alcohol? *

If yes, how many alcohol units do you consume in an average week?

Have you been advised to cut down/stop drinking alcohol, attended/referred to support specialists, or ever used recreational drugs? *

I've been advised by a medical professional to cut down or stop drinking alcohol

I've attended, or been referred, for alcohol or drug specialist support such as Alcoholics or Narcotics Anonymous

I've previously used recreational drugs in my lifetime

I've previously used recreational drugs in the last 10 years

None of these

Please tell us about your work

How many weeks / months of FULL sick pay are you entitled to through your employer?

IF OTHER - Please provide details

Are you currently off work, or working reduced hours? *

Please tell us about your health

Have you ever been diagnosed with any medical conditions by a healthcare professional? *

IF YES - Please include details such as the condition, date of diagnosis, treatment received, and whether it’s ongoing or resolved.

Are you currently taking any medication?

IF YES - Please list the name, dosage, and reason for each.

Are you currently experiencing any symptoms that you may seek medical advice for, or are you awaiting the results of any scans, tests, or referrals? *

IF YES - Please provide details.

Have you been unable to work for four weeks or more (continuously) at any point in the last five years due to illness or injury? *

IF YES - Please provide details including the reason, when it occurred, and the duration.

Have you ever consulted a GP or specialist about mental health concerns such as depression, anxiety, stress, or any other condition? *

IF YES - Please share the diagnosis (if any), treatment received, and whether the issue is ongoing.

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.