Protection Questionnaire

Financial Protection Questionnaire

First name

Last name

Birthday

Height

Weight

Any Family History of Serious Illness. If so, who and at what age were they diagnosed

Any anxiety, stress, depression in the past. If so, when, what medication and treatment has been untaken?

Have you smoked/used any tobacoo, ecigarettes or nicotine replacement products in the last 5 years. If you have stopped in that period, please confirm the date of last usage?

Have you visited your doctor in the last 5 years. If so, please provide details why?

Do you have any outstanding medical investigations or test? If so, please provide details.

Have you had any previous back issues? If so, please provide details.

Have you had more than 5 days off work in the last 5 years? If so, please provide details.

Are there any other medical conditions we should know about?

Please provide details of any hobbies you participate in and also how often?

Do you ride a motorcycle?

Please provide your job title and the duties you undertake? Can you also please confirm your annual business mileage and if your role involves foreign travel, the countries you visit.

Please provide details of your employee benefits - how much sick pay do you receive from your employer and for how long? Are there any benefits if you died?

Please provide details of any existing life, critical illness or income protection policies you may have below. You may prefer to send your existing policy schedules to us.