Protection Decision-in-Principle - lifequote.co.uk Documents... · Decision-in-Principle Data Capture Form Page 1 of 48 October 16 ... be in breach of the Data Protection Act. 3.ii:

LifeQuote Decision-in-Principle Data Capture Form

Page 1 of 48 October 16 – AL

Protection

Decision-in-Principle



Contents Check List

1. Adviser Information

Completed Yes / No Page 3

2. Provider Selection


3. Client Information and Product Solution i. Client Information

ii. Product Solution

Completed Yes / No Page 4 Completed Yes / No Pages 4 & 5

4. Occupation Page i. Occupation

ii. Commercial Fishing iii. Oil Rig / Oil Platform

Completed Yes / No Page 6 Completed Yes / No Page 7 Completed Yes / No Page 7

5. HM Forces, Territorial Army or Reserves


6. Hobbies and Pursuits i. General Information

ii. Aviation iii. Aviation Related iv. Caving / Potholing v. Equestrianism

vi. Motor Sports: Bike Racing vii. Motor Sports: Car Racing

viii. Mountaineering ix. Sports Diving x. Sailing

xi. Extreme, Other, Winter Sports

Completed Yes / No Page 9 Completed Yes / No Pages 10 & 11 Completed Yes / No Page 12 & 13 Completed Yes / No Page 14 Completed Yes / No Page 15 Completed Yes / No Page 16 Completed Yes / No Page 17 Completed Yes / No Page 18 Completed Yes / No Page 19 Completed Yes / No Page 20 Completed Yes / No Page 21

7. Medical Information i. General Information

ii. Arthritis & Gout iii. Blood Disorder or Anaemia iv. Cancer v. Chest and Respiratory Complaints

vi. Cyst, Mole, Growth, Lump or Lesion vii. Diabetes

viii. Digestive, Kidney or Liver ix. Non-Prescription Drugs or narcotics x. Epilepsy

xi. Heart Attack, Chest Pain & Angina xii. Gynaecological

xiii. HIV & Hepatitis A/B/C/D/E xiv. Joints, Bones and Muscles xv. Neurological Conditions

xvi. Blood Pressure & Cholesterol xvii. Stress, Anxiety or Depression

xviii. Stroke xix. Thyroid xx. Other Medical Conditions

Completed Yes / No Pages 22 & 23 Completed Yes / No Page 24 Completed Yes / No Page 25 Completed Yes / No Page 26 Completed Yes / No Page 27 Completed Yes / No Page 28 Completed Yes / No Page 29 Completed Yes / No Page 30 Completed Yes / No Page 31 Completed Yes / No Page 32 Completed Yes / No Pages 33 & 34 Completed Yes / No Page 35 Completed Yes / No Page 36 Completed Yes / No Page 37 Completed Yes / No Page 38 Completed Yes / No Page 39 Completed Yes / No Page 40 Completed Yes / No Page 41 Completed Yes / No Page 42 Completed Yes / No Page 43

8. Family History


9. Residency & Overseas Travel


10. Outcome: i. Summary


11. Appendix i. Key Person




ii. Shareholder Completed Yes / No Page 47

1: Adviser Information: To be completed in all cases

Adviser Name

Advisory Firm

Email Address

Preferred Contact Number

Preferred Contact Method Email / Telephone

2: Provider Selection: To be completed in all cases

Provider

Select All Yes / No

AEGON Yes / No

AIG Yes / No

Aviva Yes / No

L&G Yes / No

LV= Yes / No

Old Mutual Wealth Yes / No

Royal London Yes / No

The Exeter Yes / No

Vitality Life Yes / No

Zurich Yes / No

Notes

3: Client Information and Product Solution: To be completed in all cases



Client Reference (Please do not use your clients name as you may be in breach of the Data Protection Act.

3.ii: Client Personal Information To be completed in all cases

Gender Male / Female

Age Next Birthday (Please do not use your clients date of birth)

Marital Status Please select

Single Yes / No

Engaged Yes / No

Married Yes / No

Separated Yes / No

Divorced Yes / No

Civil Partnership Yes / No

3.2: Product Solution To be completed in all cases

Type of Application. If ‘Joint Life 1st Death’ or ‘Joint Life 2nd Death’, please complete an additional ‘Decision-in-Principle’ should it be required.

Please select

Single Yes / No

Joint Life 1st

Death Yes / No

Joint Life 2nd

Death Yes / No

Life of Another Yes / No

Reason for Cover (* If your client requires Key Person, Shareholder or Inheritance Tax Protection we have included additional Key Person Liability audit, Shareholder audit calculator and Inheritance Tax audit in the Appendix section should you wish to complete it)

Please select

Personal Protection Yes / No

Mortgage Protection Yes / No

Key Person * Yes / No

Shareholder * Yes / No

Business Loan Yes / No

Partnership Yes / No

Sole Trader Yes / No

IHT * Yes / No

School Fees Yes / No

Type of Benefit Required

Please select

Multi-Benefit Yes / No

Income Protection Yes / No

Level Life & CI Yes / No

Reducing Life & CI Yes / No

Stand Alone CI Yes / No

Level Life Yes / No

Reducing Life Yes / No

FIB Yes / No

FIB & CI Yes / No

Key Person – Life Yes / No

Key Person - Life & CI Yes / No

Shareholder – Life Yes / No

Shareholder – Life & CI Yes / No

IHT – GIV Yes / No

Whole of Life Yes / No



Sum Assured Required

Lump Sum Benefit £

Income Protection £ pm

Family Income Benefit £ pa

If ‘Multi-Benefit’, please provide a breakdown of the individual covers required

Term Required (yrs) Lump Sum Benefit Yrs

Income Protection Yrs

Family Income Benefit Yrs

TPD: What definition of incapacity does your client require?

Please select

Own Occupation Yes / No

Any Suited Occupation Yes / No

Activities of Daily Work Yes / No

Income Protection (Deferred Period) Please select

4 weeks Yes / No

8 weeks Yes / No

13 weeks Yes / No

26 weeks Yes / No

52 weeks Yes / No

Other Yes / No

In the event of incapacity, would your client receive an income from their work

Yes / No

If 'Yes', please give further details of the% of salary received and for how long the payment would be made?

Waiver of Premium Yes / No

Waiver of Premium: What definition of incapacity does your client require?

Please select

Own Occupation Yes / No

Any Suited Occupation Yes / No

Activities of Daily Work Yes / No

Does your client have any existing Life Protection, Critical Illness Protection and / or Income Protection Plans currently in-force or being applied for?

Yes / No

If ‘Yes’, please provide total existing cover

If ‘Yes’, could you let us have the details of the existing policies including Provider and Policy Numbers, if known.

If ‘Yes’, what was the purpose of the existing cover?

If ‘Yes,’ will this new application be used to replace this existing protection arrangements?

Yes / No

If’ Yes’, what is the start of the new application?



4: Occupation: To be completed in all cases

Does your client currently work in any occupation that involves any of the following duties, Manual Work (eg. lifting, carrying, working with machinery and tools), driving, working at heights or a member of the emergency services?

Yes / No

What is your client’s Employment Status Please select

Employed Yes / No

Self-Employed Yes / No

House Person Yes / No

Part-Time (under 16 hours) Yes / No

Unemployed Yes / No

Student Yes / No

Retired Yes / No

Other Yes / No

What is your client’s occupation?

Who does your client work for? (Optional)

What industry does your client work in (Optional)

How long has your client worked in their current employment?

Please provide further details of your client’s duties

How much does your client earn per annum? (£)

Does your client drive more than 18,000 business miles per annum

Yes / No

If 'Yes', please give full details of their mileage, the type of vehicle they drive and what type of licence they hold

Is your client involved in any of the following activities?

Please select

Lifting Yes / No

Carrying Yes / No

Machinery Yes / No

Tools Yes / No

Heights Yes / No

Agriculture Yes / No

Emergency Services Yes / No

Other Yes /No

If ‘Yes’, please provide full details

Is your client involved in any of the following occupations? If ‘Yes’, please complete the

Please select



relevant additional questions below. Commercial Fishing Yes / No

Oil Rig / Oil Platform Yes / No

4.1: Commercial Fishing – Additional Questions Complete as required

Commercial Fishing – Is your client Please select

Fisherman Yes / No

Deckhand Yes / No

Skipper Yes / No

Mate Yes / No

Engineer Yes / No

Fireman Yes / No

Greaser Yes / No

Mechanic Yes / No

Stoker Yes / No

Cook Yes / No

Galleyhand Yes / No

Radio Officer Yes / No

Sparehand Yes / No

Bosun Yes / No

Trainee Yes / No

Commercial Fishing – what is the size of your clients vessel

Please select

Under 24 m (80ft) Yes / No

24m – 40m (81ft-130ft) Yes / No

Over 4m (131ft +) Yes / No

Commercial Fishing – Is your client involved in any of the following activities

Please select

Crab Yes / No

Lobster Yes / No

Oyster Yes / No

Pot Yes / No

Other Yes / No

4.2: Oil Rig/Oil Platform – Additional Questions Complete as required

Oil Rig - the method of transport used to get to the oil rig or platform?

Oil Rig - where the oil rig or platform is?

Oil Rig - the name of the company that transports your client to the rig or platform?

Oil Rig - the approximate time of the journey to the rig or platform?

Oil Rig - the estimate number of journeys taken a year to the rig or platform?

Oil Rig - your client's job title?

Oil Rig - full details of your client's duties and



responsibilities?

5: HM Forces, Territorial Army & Reserves Complete as required

Is your client a member of the Armed Forces, Territorial Army or Reserves?

Yes / No

If ‘Yes’, what is your client’s role and duties?

If ‘Yes’, where is your client currently stationed? UK / Elsewhere

If ‘Yes’, what is your client’s current state of Readiness?

Please select

Under Orders Yes / No

Notice to Move Yes / No

Other Yes / No

If ‘Yes’, please tell is the country your client is due to be deployed to, known

If ‘Other’, please provide further details

Does your client belong to any of the following regiments / specialities?

Please select

Special Forces Yes / No

Parachute Regiment Yes / No

Royal Marines Yes / No

Rapid Response Unit Yes / No

Bomb Disposal Yes / No

Army Yes / No

None of the above Yes / No

Does your client take part in any military flying other than being transported to military destinations?

Yes / No

If ‘Yes’, please tell us Please select

Fast Jets Yes / No

Helicopters Yes / No

Transporters Yes / No

Other Fixed Wing

What is your client’s role? Please select

Pilot Yes / No

Other Flight Crew Yes / No

Trainee Yes / No

Aerobatics Yes / No

Winchman Yes / No

Other Yes / No

If ‘Other’, please give further details

Does your client take part in armed forces driving

Yes / No



If ‘Yes’, please provider further details

6.1: Hobbies and Pursuits: Complete as required

Does your client take part in one or more of the following hazardous hobbies or pursuits? Aviation, Aviation Related, Caving / Potholing, Equestrianism, Motor Sport, Mountaineering, Sailing/Yachting, Sports Diving, Extreme/Other/Winters Sports or as a Professional Sportsman?

Yes / No

Please select Please select

6.1: Aviation Yes / No

6.2: Aviation Related Yes / No

6.3: Caving / Potholing Yes / No

6.4: Equestrianism Yes / No

6.5: Motor Sports: Biking Yes / No

6.6: Motor Sports: Car Yes / No

6.7: Mountaineering Yes / No

6.8: Sports Diving Yes / No

6.9: Sailing / Yachting Yes / No

6.10: Other Extreme Sports Yes / No



6.2: Aviation:

Please select

Pleasure Flying Yes / No

Business Flying Yes / No

Flying Instructor Yes / No

Other type of flying Yes / No

Aerobatics or Stunt Flying Yes / No

Pleasure Flying

What category of licence does your client hold? Please select

Student Yes / No

Private Pilot Yes / No

Commercial Pilot Yes / No

Which type of aircraft does your client normally fly? (make, model, number)

What is the aircraft weight?

How many flying hours does your client have?

How many flying hours does your client have in the last 12 months?

What do you estimate your client's flying hours will be in the next 12 months?

Business Flying

What category of licence does your client hold?

Which type of aircraft does your client normally fly? (make, model, number)


How many flying hours does your client have in the last 12 months?


What type of business does your client fly for?

Who owns the aircraft your client is likely to use?

What are the geographical limits your client is likely to fly in?

Does your client take part in low-level flying, such as crop spraying?

Yes / No

If ‘Yes’, please give full details

Flying Instructor




What type of training does your client give, eg club, commercial, ab initio (beginners) or advanced training?

Other types of flying

Please give us full details of the type of aviation your client takes part in and the type of aircraft they fly?

What category of licence does your client hold?



What are the geographical limits your client is likely to fly in?

Does your client take part in aerobatics, competition flying, stunt flying or experimental flying?

Yes / No




6.3: Aviation Related: Please complete all that apply

Please select the type of flying your client takes part in?

Please select

Ballooning Yes / No

Gliding Yes / No

Hang-Gliding Yes / No

Power Hang-Gliding Yes / No

Paragliding Yes / No

Parachuting Yes / No

Ballooning

Please confirm the average number of hour your client fly’s per year.

Please confirm whether

Please select

Tethered Yes / No

Free Flight Yes / No

Both Tethered and Free Yes / No

Please confirm total hours of experience

Gliding

What type of glider does your client use? Self-Launching Glider / Unpowered

Does your client take part in stunt or record flying?

Yes / No


Please confirm the average number of hours your client fly’s per year

Hang-Gliding

Does your client take part in any record attempts or prototype testing?

Yes / No


Is your client a member of the British Hang-gliding and Paragliding Association (BHPA)?

Yes / No

Does your client hold a pilot rating for cross-country or instructor?

Yes / No

Please confirm the average number of hours your client fly’s a year.

Powered Hang-Gliding/micro lighting


Please confirm the average number of hours



your client fly’s a year.

Paragliding

Is your client a member of the British Hang-gliding and Paragliding Association (BHPA)?

Yes / No


Parachuting

What type of jumps does your client do? Please select

Static Line Yes / No

Free Fall Yes / No

Both Yes / No

Please confirm the average number of jumps your client completes a year.

Does your client belong to a parachuting club? Yes / No


Has your client ever taken part in a public display?

Yes / No




6.4: Caving / Potholing:

How often does your client go caving per annum?

Where does your client go caving?

How long has your client been caving?

Has your client ever had any training? Yes / No


Is your client a member of any caving clubs? Yes / No


Does your client ever cave or pothole alone? Yes / No


Has your client ever done, or do they intend to do, any of the following?

Single rope techniques Yes / No


Cave Diving Yes / No


Digging or exploring new mines Yes / No


Exploring abandoned mines Yes / No




Has your client ever been involved in a rescue? Yes / No


6.5: Equestrianism:

Is your client either Please select

Professional/Sponsored Yes / No

Amateur Yes / No

Which of the following does your client do Please select all that apply

Dressage Yes / No

Endurance Yes / No

Gymkhana Yes / No

Pony Club Yes / No

Hacking Yes / No

Showing Yes / No

Show Jumping Yes / No

Vaulting Yes / No

Harness racing Yes / No

Hunter chasing Yes / No

Hunter trials Yes / No

Hunting Yes / No

One-day events Yes / No

Point to Point Yes / No

Team chasing Yes / No

Three-day events Yes / No

Polo Yes / No

Instructor Yes / No



6.6: Motor Sports: Bike Racing

Is your client's motor sport restricted to track days?

Yes / No

If 'Yes', please give full details, including frequency of participation and circuit/venue details.

Under what status does your client compete? Please select


Amateur Yes / No

What type of races does your client take part in Please select all that apply

Circuit racing Yes / No

Trial Yes / No

Motocross (scrambling) Yes / No

Hill climbs Yes / No

Other Yes / No


What is the model and size of your client’s vehicle?

Please confirm the average number of events your client takes part in a year.

Does your client take part in the following Please select all the apply

Time Trial (TT) Yes / No

Grand prix Yes / No

World championship racing Yes / No

Please confirm the number of events your client has taken part in to date in total.

Please confirm the number of events your client has taken part in over the past year.



Please confirm the number of events your client expects to take part in over the next year.

6.7: Motor Sports: Car Racing

Does your client complete as: Please select


Amateur Yes / No

What type of races does your client take part in Please select all that apply

Cart Yes / No

Indy Yes / No

Formula 1 Yes / No

Formula 3000 Yes / No

Formula 3 Yes / No

ASCAR Yes / No

Cross country Yes / No

Hill Climbs Yes / No

Speed trials Yes / No

Stock car racing Yes / No

Saloon car racing Yes / No

Karting Yes / No

Rallying Yes / No

Other, please give full details

What is the model and engine size of your client's vehicle?

Is your client's motor sports participation restricted to track days?

Yes / No

If 'Yes', please give full details of frequency of participation and circuit/venue details.



6.8: Mountaineering:

When and where did your client learn to climb?

What level of competence has your client reached, (eg novice, instructor)?

Please tell us the degree of difficulty of the climbs your client undertakes.

Please select

Easy Yes / No

Difficult Yes / No

Severe Yes / No

Extremely severe Yes / No

Please tell us the type of terrain your client climbs in, eg snow, ice, rock etc.

Is your client a member of a club? Yes / No

If 'Yes', please give its name and tell us whether it's affiliated to the British Mountaineering Council

How often does your client climb each year?

Where and how often does your client intend to climb (eg UK only, Europe, Asia)?

Does your client ever climb alone? Yes / No

If 'Yes', please give us full details of any climbing accidents your client has had

What is the maximum height your client intends to climb to?



6.9: Sailing & Yachting:

Please select

Pleasure Only Yes / No

Racing Yes / No

Pleasure Only

Where does your client sail? Please select

Inland Yes / No

Offshore Yes / No

Please confirm how many crew members your client would usually have?

Racing

Does your client race professionally? Yes / No

Where does your client race? Please select

Inland Yes / No

Offshore Yes / No

What type of event does your client participate in?

Please select

Short races Yes / No

Races across open water Yes / No

Extended races Yes / No

Trans-Ocean Yes / No

Please confirm how many crew members your client would usually have?

Does your client take part, or have any intention of taking part, in a single-handed around-the-world race?

Yes / No




6.10: Sports Diving

What dive qualifications does your client currently hold?

Please select

None Yes / No

Not Known Yes / No

PADI Discovery Yes / No

PADI Open Water Yes / No

PADI Advanced Open Water Yes / No

PADI Dive Master Yes / No

PADI Instructor Yes / No

Other Yes / No

If ‘Other’, please give details

On average, how many dives does your client make per year?

What is the maximum depth your client dives to (metres)?

Please tell us if your client takes part in any of the following:

Please select

Internal exploration wrecks Yes / No

Diving for treasure Yes / No

Special Expeditions Yes / No

Diving unaccompanied Yes / No

Cave & pothole diving Yes / No

Depth records attempts Yes / No

Diving bells Yes / No

Other Yes / No

If ‘Other’, please give details



6.11: Other Extreme Sports

Does your client participate in any other extreme hobby or pursuit?

Please select

Base Jumping Yes / No

Boxing Yes / No

Bungee Jumping Yes / No

Professional Sport Person Yes / No

Winter Sports Yes / No

Wrestling Yes / No

Zorbing Yes / No

Other Yes / No

Base Jumping

If ‘Base Jumping’, please supply further details including dates, frequencies and heights?

Boxing

If ‘Boxing’, please confirm weight category, number of fights per year and any other information you feel appropriate?

Bungee Jumping

If ‘Bungee Jumping’, please supply further details including dates, frequencies and heights?

Professional Sport Person

If ‘Professional Sports’ person, please confirm the sport involved, team and length of contract?

Winter Sports

If ‘Winter Sports’, please provide full details?

Wrestling

If ‘Wrestling’, please confirm weight category, number of fights per year and any other information you feel appropriate?

Zorbing



If ‘Zorbing’, please provide full details?

Other

If ‘Other’, please provide full details?

7.1: Medical Information:

Has your client ever had any major medical condition and / or surgery, had a medical condition in the last 5 years even if they've not consulted with a medical professional, or are they awaiting the results of a medical investigation or currently taking any form of prescription medication?

Yes / No

Medical Condition Yes / No

Awaiting Test Results Yes / No

Current Medication Yes / No

Has your client previously had an application for any Life Assurance Benefit declined, refused, rated, excluded, or ever used any form of non prescription drug or narcotic?

Yes / No

Declined/Refused Yes / No

Postponed Yes / No

Rated Yes / No

Excluded Yes / No

Non-Prescription Drug Yes / No

If ‘Declined’, ‘Postponed’, ‘Rated’, ‘Excluded’, ‘Medical Condition’, ‘Non-Prescription Drug’, ‘Awaiting Test Results’ or ‘Current Medication’, please give details.

Please could you ask you client to supply their height and weight wearing indoor clothes and without their shoes on please? What is your client's weight (kg's or stones & pounds)? If your client is pregnant, please confirm their pre-pregnancy weight

When was the last time your client weighed themselves (mm/yyyy)?

What is your client's height (cm or feet and inches)?

If known, could you let us have your client's current Body Mass Index (BMI)? (Optional)

Please select

Not known Yes / No

Underweight Yes / No

Normal Yes / No

Overweight Yes / No

Obese Yes / No



Non-Prescription Drug Yes / No

Current Medication Yes / No

Does your client smoke Yes / No

If 'Yes', can you please give full details including what they smoke, how often they smoke and whether they are using any form of nicotine replacement products

If 'No', has your client ever smoked or used any form of nicotine replacement product?

Yes / No

If 'Yes', please give us full details

Does your client drink alcohol? Yes / No

If 'Yes', please give details of the amounts, frequency and type of alcohol they drink

Yes / No

Has your client ever been advised by a medical professional to stop drinking alcohol

Yes / No

If ‘Yes’, please give further details

Medical Conditions Please complete all questionnaire that apply

Please select

7.1: Arthritis & Gout Yes / No

7.2: Blood or Anaemia Yes / No

7.3: Cancer Yes / No

7.4: Chest & Respiratory Yes / No

7.5: Cyst, Mole, Growth etc Yes / No

7.6: Diabetes Yes / No

7.7: Digestive, Kidney, Liver Yes / No

7.8: Non-Prescription Drugs Yes / No

7.9: Epilepsy Yes / No

7.10: Gynaecological Yes / No

7.11: Heart Attack Chest Pain Yes / No

7.12: HIV & Hepatitis ABCDE Yes / No

7.13: Joints, Bones & Muscle Yes / No

7.14: Neurological Yes / No

7.15: Raised Blood Pressure Yes / No

7.16: Stress, Anxiety, Dep Yes / No

7.17: Stroke Yes / No

7.18: Thyroid Yes / No

7.19: Other, eg ears, eyes etc Yes / No



7.ii: Arthritis & Gout:

Please confirm your client's exact diagnosis Please select

Rheumatoid Arthritis Yes / No

Osteoarthritis Yes / No

Other Arthritis Yes / No

Gout Yes / No

Which joints does this affect? (Please specify left or right as appropriate)

Please give a brief description of your client's symptoms and the effect they have on their daily life

Please tell us what medication / treatment your client receives?

Please give the date of your client's last attack, if applicable (dd/mm/yyyy)

Has your client had to take time off work because of their condition?

Yes / No

If ‘Yes’, please give the number of instances and dates?

Can you give us any more information that you feel will help us to consider this enquiry further?



7.iii: Blood and Anaemia:

Blood Conditions

What is the exact medical diagnosis?

How long ago was your client diagnosed? (mm/yyyy)

Is your client currently receiving medication and/or treatment?

Yes / No

Does your client have their blood levels checked?

Yes / No


Is your client currently waiting for any investigation?

Yes / No


Anaemia

If known, please tell us the type of anaemia: Please select

Iron Deficiency Anaemia Yes / No

Sickle Cell Anaemia Yes / No

Thalassaemia Yes / No

Other Yes / No

Unknown Yes / No

If your client has Iron Deficiency Anaemia, has an underlying cause been found?

Yes / No

If ‘Yes’ please give full details

If you've ticked 'other' or 'unknown' in the previous list, please give full details where possible.

Has your client ever been advised by a medical practitioner that their blood levels have returned to normal?

Yes / No

If ‘No’, please give full details




7.iv: Cancer:

Please confirm the type of cancer your client has been diagnosed with?

Please select

Bladder Cancer Yes / No

Breast Cancer Yes / No

Colon & Rectal Cancer Yes / No

Endometrial Cancer Yes / No

Renal Cancer Yes / No

Leukaemia Yes / No

Lung Cancer Yes / No

Melanoma Yes / No

NonHodgkin Lymphoma Yes / No

Pancreatic Cancer Yes / No

Prostate Cancer Yes / No

Thyroid Cancer Yes / No

Other Yes / No

If ‘Other’, please supply full details

Please confirm the site / sites where the cancer has been diagnosed?

Please confirm the date of the initial diagnosis? (dd/mm/yyyy)

Is your client currently taking medication in relation to this condition?

Yes / No

If 'Yes', please give further details

Has your client taken medication in relation to this condition in the past?

Yes / No

If 'Yes', please give further details, including dates and frequencies?

Please provide details of the histology, stage and grade of your client's tumour / tumours?

Has your client's tumour spread from the original site of diagnosis?

Yes / No

If 'Yes', please give further details including dates (dd/mm/yyyy) and site

Is your client currently undergoing any follow-up treatment?

Yes / No

If 'Yes', please give further details including dates (dd/mm/yyyy) and duration

Has your client experienced any form of relapse? Yes / No


Please provide any additional information about your client's condition that you feel will be



helpful when assessing this enquiry

7.v: Chest and Respiratory Complaints:

Please can you give us the exact medical diagnosis of your client's chest complaint

How long has your client had this condition?

Please describe your client's symptoms, for example cough, wheeziness, shortness of breath

How often is your client affected and what was the date of their last attack?

What brings on an attack, eg exercise, stress, allergy?

Has your client ever had any hospital investigation?

Yes / No

If 'Yes', please give details, including results and dates

Has your client ever been hospitalised because of an attack?

Yes / No

If 'Yes', please give details, including results and dates

Has your client ever had their Peak Flow Rate measured?

Yes / No

If 'Yes', when and what was the result?

What medication is your client currently being prescribed and how often do they take it?

What medication or surgery has your client received in the past, eg Becotide, Intal, Ventolin?

Has your client ever been prescribed steroids, eg Prednisone?

Yes / No

If 'Yes', please tell us when and for how long?

Has your client ever been absent from work with this condition?

Yes / No

If 'Yes', please give dates and lengths of absences.

Is your client currently having or has had regular follow-up checks?

Yes / No

If 'Yes', please tell us how often and who with.




7.vi: Cysts, Moles, Growths and Lesions:

Please give us the precise medical diagnosis

Please confirm the exact site of the growth.

How long ago did your client first seek medical attention for this condition?

Please select

Within the last 6 months Yes / No

More than 6 months ago Yes / No

Never Yes / No

Please give details of any investigations or tests carried out including results if known

Has the growth ever been completely removed? Yes / No

If ‘Yes], please provider full details

Has the growth been confirmed as benign (non-cancerous)?

Yes / No


Is your client currently receiving follow-up checks?

Yes / No

If 'Yes', please give the date next follow-up appointment (dd/mm/yyyy)




7.vii: Diabetes:

Please tell us the type of diabetes your client has been diagnosed with:

Please select

Type 1 insulin dependent Yes / No

Type2 non-insulin dependent Yes / No

Sugar in urine Yes / No

Diabetes during pregnancy Yes / No

Other Yes / No

If 'Other', please give further details

When was your client diagnosed? Please select

0 – 6 months ago Yes / No

7 months - 5 year ago Yes / No

6 – 15 years ago Yes / No

Over 16 years ago Yes / No

When did your client last have their blood sugar level checked?

Please select

0 – 6 months ago Yes / No

7 plus months Yes / No

What is your client's usual average blood sugar reading (in mmol/l)?

Please select

Less than or equal to 7.8 Yes / No

7.9 - 11 Yes / No

11.1+ Yes / No

Hba1c Yes / No

If ‘Hba1c’, please provide full details

Has your client ever had any problems with the following, which are related to diabetes?

Please select

Eyes Yes / No

Heart Yes / No

Nervous System Yes / No

Kidney Yes / No

Feet Yes / No

None Yes / No

How many hospital admissions due to diabetic coma or hypoglycaemic attacks has you client had in the last 5 years?

Please select

0 Yes / No

1 Yes / No

2 Yes / No

3 Yes / No

4 Yes / No




7.viii: Digestive, Kidney or Liver:

What precise medical diagnosis has your client been given by their doctor?

How long has your client had the symptoms?

When did the symptoms last occur (dd/mm/yyyy)?

What medication is your client currently taking and often do they take it?

Has your client had any form of surgery related to this condition?

Yes / No

If 'Yes', please give full details and results.

Has your client had any investigations for their condition?

Yes / No


Is your client currently getting any follow-up checks?

Yes / No


If your client's checks are complete, please give us the date of their last check (dd/mm/yyyy)




7.ix: Non-Prescription Drugs and Narcotics:

Has your client ever used any of the following non-prescriptions drugs or narcotics?

Amphetamines (eg ecstasy, ice, MDMA, speed, uppers, etc)

Yes / No

Barbiturates (eg downers, phenobarbitone, etc) Yes / No

Cannabis (eg hashish, marijuana, pot, weed, etc) Yes / No

Cocaine (eg coke, crack, snow, etc) Yes / No

Hallucinogenics (eg acid, LSD, angel dust, opium, morphine, smack, etc)

Yes / No

Opiates (eg heroin, methadone, codeine, opium, morphine, smack, etc

Yes / No

Sedatives (eg diazepam, downers, mirtazapine, tranqs, etc)

Yes / No

Others Yes / No

If ‘Others’, please give us full details of the substances involved, dates and whether any medical advice was sought during this period

Please supply details of your client's last date of use, drug used, quantity and frequency?

Has your client ever sought medical treatment for drug use or undergone detoxification?

Yes / No

If 'Yes', please give details, including dates of attendance and name of doctor

Has your client ever taken drugs intravenously? Yes / No

If 'Yes', please give details, including source of needles and if needles were ever shared

Has your client ever suffered from any medical condition associated with drug use, such as hepatitis, mental illness, etc?

Yes / No

If 'Yes', please give full details.




7.x: Epilepsy:

Please give the date and nature of the initial medical diagnosis

Has your client ever had any investigations? Yes / No

If 'Yes', please give details including dates and results

Does your client suffer from attacks that are petit mal or grand mal? If either, please give full details

Yes / No

How long does each attach last?

What was the date of your client's last attack (dd/mm/yyyy)?

Does anything cause your client's attacks? Yes / No


Please give details of your client's medication, including how often do they take it?

What medication has your client received in the past? Please provide full details

Is your client having regular follow-up checks? Yes / No


Is your client permitted to hold a UK driving licence?

Yes / No

If 'No', please give further details




7.xi: Heart Attack, Chest Pain & Angina - 1:

What was the date of your client's first attack (dd/mm/yyyy)?

Where was the location of the chest pain? Please select

Central Yes / No

Left side of chest Yes / No

Right side of chest Yes / No

Across front of chest Yes / No

Other Yes / No


What was the severity of the pain? Please select

Vague discomfort Yes / No

Dull ache Yes / No

Stabbing pain Yes / No

Sharp pain Yes / No

Vice-like pain Yes / No

Crushing pain Yes / No

Very severe pain Yes / No

Did your client's pain radiate outside the chest? E.g. to the shoulders, arms, jaw, abdomen?

Yes / No


What were the circumstances that caused your client's chest pain?

Please select

Sudden Yes / No

Gradual Yes / No

At rest Yes / No

Only on effort Yes / No

Change of posture Yes / No

How long did the pain last?

What investigations were carried out and what were the results?

What was the final diagnosis?

Has your client ever had heart surgery, heart bypass surgery or angioplasty?

Please select

Heart Surgery Yes / No

Heart Bypass Surgery Yes / No

Angioplasty Yes / No

No Yes / No



If 'Heart Surgery', please provider full details including dates and number of vessels

7.xi: Heart Attack, Chest Pain & Angina - 2:

If 'Heart Bypass Surgery', please provider full details including dates and number of vessels

If 'Angioplasty', please provider full details including dates and number of vessels

Does your client experience angina, difficulty breathing or pain in their calves?

Yes / No

If 'Yes', please give further details including dates (dd/mm/yyyy) and duration?

Please provide details of any treatment

Is the treatment still continuing? Yes / No


Has there been any recurrence of the symptoms?

Yes / No


Did the symptoms cause your client any incapacity or time off work?

Yes / No


Please provide any additional information about your client's condition that you feel will be helpful when assessing this enquiry



7.xii: Gynaecological

Please confirm the exact diagnosis.

Please give full details of your clients’ symptoms.

Please confirm what treatment or medication your client has received?

Has your client had investigations for this problem?

Yes / No

If 'Yes', what was the outcome of these investigations?

Is your client receiving follow-up checks? Yes / No


Has your client had surgery for this condition? Yes / No

If 'Yes', or they are awaiting surgery, please supply details

Has your client had their condition confirmed as benign (non-cancerous)?

Please select

Benign Yes / No

Not Benign Yes / No

If 'Not Benign', please give further details

Please can you confirm the date of your client's last cervical smear (dd/mm/yyyy)?




7.xiii: HIV & Hepatitis A,B,C,D,E:

What is your client's current diagnosis? Please select

HIV / AIDS Yes / No

Hepatitis A Yes / No

Hepatitis B Yes / No

Hepatitis C+ Yes / No

Hepatitis D Yes / No

Hepatitis E Yes / No

HIV / AIDS

Has your client tested positive to HIV/AIDS? Yes / No

If 'Yes', please confirm the date of their diagnosis (dd/mm/yyyy), details of any medication or treatment programme and a brief description of their current symptoms?

Hepatitis A

Has your client tested positive to Hepatitis A? Yes / no


Hepatitis B

Has your client tested positive to Hepatitis B? Yes / No


Hepatitis C +

Has your client tested positive to Hepatitis C+? Yes / No


Hepatitis D

Has your client tested positive to Hepatitis D? Yes / No


Hepatitis E

Has your client tested positive to Hepatitis e? Yes / No




7.xiv: Joints, Bones and Muscles:

Please give the exact diagnosis your client's condition.

If applicable, please tell us which joint, bone or muscle was involved, indicating left, right or both as appropriate

Is there an underlying cause to your client's disorder, eg osteoporosis or a tumour?

Yes / No

If 'Yes', please give full details

How long ago did the symptoms first appear? (dd/mm/yyyy)

Was this a single episode of symptoms? Yes / No

If ‘No’, please provide further details

Does your client have ongoing symptoms? Yes / No

If ‘Yes’, does your client currently receive medication or treatment for their condition?

If ‘Yes’, does your client currently receive medication or treatment for their condition?

Has your client had surgery for this condition? Yes / No

If 'Yes', when did your client have surgery? (dd/mm/yyyy)

If 'Awaiting Surgery', please give an estimated date of surgery? (dd/mm/yyyy)

Has your client's condition caused them to be absent from work?

Yes / No

If 'Yes', please give dates and duration

Is your client currently absent from work due to this condition?

Yes / No

If ‘Yes’, please give dates and duration

Is your client now fully recovered with no ongoing symptoms?

Yes / No



If 'No', please give full details


7.xv: Neurological Disorders


Alzheimer’s Disease Yes / No

Brain Related Conditions Yes / No

Multiple Sclerosis Yes / No

Parkinson’s Disease Yes / No

Other Yes / No

Alzheimer’s Disease

If 'Alzheimer's', please confirm the date of their diagnosis (dd/mm/yyyy), details of any medication or treatment programme and a brief description of their current symptoms?

Brain Related Conditions

If 'Brain Related Condition', please confirm the date of their diagnosis (dd/mm/yyyy), details of any medication or treatment programme and a brief description of their current symptoms?

Multiple Sclerosis

If 'Multiple Sclerosis', please confirm which type Please select

Relapsing Remitting (RRMS) Yes / No

Primary Progressive (PPMS) Yes / No

Secondary Progressive (SPMS)

Yes / No

Benign MS Yes / No

When did your client first notice symptoms of MS? (dd/mm/yyyy)?

How old was your client when they were first diagnosed with MS (yrs)?

What are your client's current symptoms

What is the frequency of your client's attacks?

What was the date of your client's last attack (dd/mm/yyyy)?

Please provide details of any medication your client has taken or is currently taking in relation to this condition?

Does your client currently experience in disability as a result of their MS?

Yes / No


Has your client had time off work as a result of their condition?

Yes / No

If 'Yes', please give further details including dates



(dd/mm/yyyy) and duration

Parkinson’s Disease

If 'Parkinson's', please confirm the date of their diagnosis (dd/mm/yyyy), details of any medication or treatment programme and a brief description of their current symptoms?

7.xvi: Raised Blood Pressure & Cholesterol

When did your client first notice their raised blood pressure (mm/yyyy)?

How was this discovered and why was their blood pressure measured at that time

What was your client's blood pressure readings at the time (if known)

Has your client had time off in the last 5 years? Yes / No

If 'Yes', please tell us when and for how long.

What treatment has your client received in the past? Please give full details and dates.

What tablets (drug name and dosage) is your client currently being prescribed and how often do they take them?

Has your client undergone and investigation with regard to their condition, eg electrocardiogram, chest X-ray, kidney scan?

Yes / No


Is your client having regular follow-up checks with their GP or at hospital?

Yes / No


Has your client ever had their blood lipid level checked (for cholesterol, triglycerides, etc.)?

If ‘Yes’, please provide full details of dates and results (exact readings if known)

Has your client ever had a stroke or any kidney, heart or eye problems?

Yes / No


Has your client's urine checks always been normal?

Yes / No


Have your client’s biological parents, brothers or sisters died or suffered from heart disease,

Yes / No



stroke, high blood pressure, and diabetes or kidney disease?


Can you give us any extra information that you feel will help us consider this application further?

7.xvii: Stress, Anxiety and Depressions

Please tell us the medical diagnosis your client has been given.

When did the symptoms begin and what was the nature of your client's symptoms?

How often has your client suffered these symptoms since their initial diagnosis?

Has your client's condition caused them to be absent from their normal activities

Yes / No

If 'Yes', please give details

Has your client ever been treated with drugs? Yes / No

If 'Yes', please give us full details

Current Treatment (drug name and daily usage)

Previous Treatments (drug name and daily usage)

Has your client ever been treated as an impatient?

Yes / No

If 'Yes', please tell us where this was and when, in each case

If ‘Yes’, please tell us what treatment your client has received.

Has your client ever been treated as an outpatient or referred to a psychiatrist?

Yes / No

If 'Yes', please give us details the consultations including dates

Please tell us what treatment your client has received

Is your client having regular follow-up checks? Yes / No

If 'Yes', please tell us how often and who with

Has your client ever attempted suicide? Yes / No

If 'Yes', please give us details and dates

Was there any particular cause for your client's Yes / No



stress, anxiety or depression?

If 'Yes', please give details

Can you give us any extra information that will help us consider this enquiry further?

7.xviii: Stroke


Ischemic Stroke Yes / No

Hemorrhagic Stroke Yes / No

Ischemic Stroke

Please confirm which type Please select

Embolism Yes / No

Systemic Hypoperfusion Yes / No

Thrombosis Yes / No

Venous Thrombosis Yes / No

Hemorrhagic Stroke

Please select

Intracerebral Hemorrhagic Yes / No

How old was you client when they experienced their first episode (age)?

What was the date of your client's first episode (dd/mm/yyyy)?

What was the severity of your client's neurological impairment?

What is the severity of the underlying causes of your client' impairment?

If there evidence of the presence of CAD? Yes / No


Does your client present any co-morbid diseases related to their current impairment?

Yes / No


Can you give us any extra information that will help us consider this enquiry further?



7.xix: Thyroid:

Please give us the precise definition? Please select

Hyperthyroidism Yes / No

Hypothyroidism Yes / No

Goitre Yes / No

Other Yes / No

If’ Other’, please give full details

How long ago was your client first diagnosed? (mm/yyyy)

Has your client had investigations for this condition?

Yes / No / Awaiting

Does your client take prescribed medication or have they received treatment for this condition?

Yes / No

If 'Yes', please give full details

Has your client ever been advised by a medical practitioner that their blood levels have returned to normal?

Yes / No

If 'No', please give full details

Does your client have their blood levels checked for this condition?

Yes / No

If 'Yes', please tell us the date of your client's last blood test and results




7.xx Other Medical Conditions: Eg, Ears, Eyes etc

Please give us full details of any other medical condition your client may have including a full diagnosis, dates and names of any medication they have or are currently taking?

What medical condition is your client currently experiencing or has experienced in the past

When was this condition first diagnosed (dd/mm/yyyy)?

Is your client currently taking any medication in relation to this condition?

Yes / No


Please provide details of any surgical intervention your client has experienced in relation to this condition?

Please provide details of any medication your client has taken in relation to this condition?

Does your client currently experience any symptoms whatsoever that could be attributed to this condition?

Yes / No





8: Family History:

Please give details if your client's ‘Biological’ parents, brother or sisters have died or suffered from any of the following before the age of 65? - heart disease, stroke, diabetes, cancer or tumour, Alzheimer's disease, Parkinson's disease, polycystic kidney disease, polyposis of the colon, motor neurone disease, multiple sclerosis, Huntington's disease, muscular dystrophy, hypertrophic cardiomyopathy (HOCM) or any other hereditary disorder.

Yes / No

Relative 1

If ‘Yes’, please confirm details of the relative Please select

Father Yes / No

Mother Yes / No

Brother Yes / No

Sister Yes / No

Please confirm the medical condition involved?

Please confirm the year of the initial diagnosis? (yyyy)

Please confirm the age of diagnosis?

If 'Brother', was he an identical twin?

Yes / No

If 'Sister', was she an identical twin? Yes / No

Relative 2

If ‘Yes’, please confirm details of the relative Please select

Father Yes / No

Mother Yes / No

Brother Yes / No

Sister Yes / No

Please confirm the medical condition involved?

Please confirm the year of the initial diagnosis? (yyyy)

Please confirm the age of diagnosis?

If 'Brother', was he an identical twin?

Yes / No

If 'Sister', was she an identical twin? Yes / No



9: Residency & Overseas Travel:

Is your client resident in the UK (excluding The Channel Islands and The Isle of Man)?

Yes / No

If 'No', please provide full details including Countries' visited, duration, frequency

Has your client travelled overseas for a continuous period of more than 90 days in the last 5 years?

Yes / No

If ‘Yes’, please give further details including dates (dd/mm/yyyy), duration and details of countries visited



10: Outcome

Did this case proceed Yes / No

If ‘Yes’, please confirm the Provider Select All Yes / No

AEGON Yes / No

AIG Yes / No

Aviva Yes / No

L&G Yes / No

LV= Yes / No

Old Mutual Wealth Yes / No

Royal London Yes / No

The Exeter Yes / No

Vitality Life Yes / No

Zurich Yes / No

If ‘Yes’, please confirm the Terms Offered

If ‘Yes’, what is the Policy Number

If ‘Yes’, was the ‘Decision-in-Principle’ Accurate? Yes / No

If ‘No’, how did the Terms Offered differ?

If the case did not proceed, please confirm the reasons

Other Information



Appendix

Business Protection: Generally, if your client's application exceeds £ 1m Life Protection and/or £ 500,000 Critical Illness or TPD you will normally need to provide further Financial Underwriting information, eg, Business Protection Questionnaire, Copy of Loan Agreement, Last two years' audited accounts and copy of the valuation report. Please contact your preferred Provider / Providers direct for this information

1: Key Person – Liability Audit (Optional)

A. Total liabilities to third parties (£) (Liabilities to third parties include all bank loans and details of current overdraft limits and whether they are fully used)

B. Total liabilities to owners (£) (Liabilities to owners include outstanding director's credit loan accounts)

C. Loss of profit x term to recovery (£) (This is based on the net profit of the business, how much of the profit can be attributed to the business owners, how much profit can be attributed to another / other key person(s), how long would it take the business to recover the loss of this key person)

D. One-off expenses (£) (One-off expenses include total recruitment costs)

Total (A+B+C+D) = (£) (Please add the liabilities to third parties, liabilities to owners, loss of profit x term to recover and any one-off expenses)

2: Shareholder (Optional)

What is the name of your client's Company?

What is the latest Company Valuation?

How many Shareholders are there?

What is your client's Shareholding (%)?

Who does your client want his shares to go to on his death and in what proportion?

3: Inheritance Tax (Optional)

What is the estimated IHT Liability?

Please confirm how the IHT Liability was calculated?

Who will the IHT liability fall on?

Please confirm details of any relief(s) that will be available for the mitigations of IHT, eg business



relief