Life Insurance Questionnaire Here are some initial questions that we need from you to get a quote. We may come back to you with more questions depending on your conditions. Name * First Name Last Name Date of Birth * Business name * Occupation * Home Address * Annual Salary * Height and Weight * Alcohol consumption In average of a week how many alcoholic drinks do you have? Include pint of beer, cider, average sized glass of wine a single measure of spirits * Doctor Surgery Name and Address * Medical History Have you ever tested positive for COVID 19? * Yes No In the last month have you been personally advised to self-isolate by a medical professional or the NHS 111 but have not been diagnosed with Coronavirus, had a new continuous cough and / or high temperature, or had direct contact with someone who's been confirmed or suspected to have Coronavirus? (Please answer No if the only contact is related to working as a medical professional or this relates to a Coronavirus infection already disclosed) * Yes No Do you already have any Life Cover, Critical Illness / Serious Illness or Income Protection Cover with VitalityLife (formerly known as PruProtect)? * Yes No Within the last 12 months have you applied for any other cover with VitalityLife, regardless of whether a policy has been issued or not? Yes No Do you intend to submit an additional application to VitalityLife for Life, Serious illness or Income Protection cover at this time? * Yes No Including this application, will the total amount of Life Cover you have for all purposes exceed £2 million? (Ignore cover that will be cancelled and applications that are for comparative purposes only, but include any further cover you intend applying for in the next 6 months) * Yes No Recent Health Have you ever been diagnosed with or experienced any of the following: Cancer, tumour, Hodgkin's disease, leukaemia or lymphoma? • Heart abnormality, including heart-related chest pain, heart attack or heart valve disease? • Stroke, brain haemorrhage or brain injury? • Mental illness that has required hospital admission? • Diabetes? • Multiple sclerosis, Parkinson's disease, paralysis, epilepsy, Alzheimer’s disease or dementia? • HIV, Hepatitis B or C? If yes, please provide more details In the last 5 years have you had any of the following: • Raised blood sugar, blood pressure, or cholesterol? • Asthma, sleep apnoea or anything else affecting your breathing or lungs? • Any mental illness including depression, stress, anxiety or eating disorder? • Any disorder of the kidneys or digestive system including the liver, stomach, pancreas and bowel? • Any lump, growth or polyp, or any mole that has changed in appearance? If yes, please provide more details Apart from anything you've already told us about, in the last 3 years have you: Been advised to have or undergone any medical investigation such as blood tests, x-rays, urine tests, scans, exploratory surgery, biopsies / tissue sampling or internal camera investigation? If yes, please provide more details Been prescribed any medication, treatment or counselling that lasted for two weeks or more If yes, please provide more details Seen or been asked to see any medical professionals more than once in connection with the same medical condition? If yes, please provide more details Are you currently waiting for the results of any tests / investigations or experiencing symptoms that you are likely to seek medical advice or treatment for? If yes, please provide more details Before the age of 60, have any members of your immediate family (natural parents, brothers or sisters) had any of the following medical conditions: Breast, Ovarian, Prostate, Colon or Bowel Cancer, Heart Attack, Angina, Cardiomyopathy, Diabetes, Multiple Sclerosis, Muscular Dystrophy, Parkinson's, Dementia / Alzheimer's Disease, Huntington's, Motor Neurone Disease or Polycystic Kidney Disease? If yes, please provide more details Are there any other conditions that run in your family that you have had, or been advised to have ongoing screening / monitoring for? If yes, please provide more details Lifestyle Questions Have you ever been advised to reduce your alcohol intake because you were drinking too heavily, or within the last 10 years, have you taken recreational drugs such as cannabis, ecstasy, cocaine, methadone, heroin, anabolic steroids or similar substances? * Yes No In the next 12 months, do you intend spending more than 4 weeks overall (i.e. in total across all of these areas) in the Middle East, Africa, Central or South America, Asia (ignore Japan, Hong Kong and Singapore), Ukraine, Russia or New Guinea? * Yes No Do you take part in or intend to take up any hazardous activities? Examples include but are not limited to aviation, (except as a fare paying passenger or where it is your full time occupation), parachuting, skydiving, hang-gliding, water sports, diving, mountaineering, caving, bouldering, motor sports, extreme sports (such as bungee jumping, base jumping, canyoning) etc. One day experience or taster sessions can be ignored. * Yes No Do you have any existing life insurance cover? If yes, please write the details. * Thank you for submitting your Life Insurance Questionnaire. We will get back to you with our findings in the next 24 hours.
