Hi

Thank you for applying for this policy. Just a couple of steps before we can help you get your cover in place.

do you currently have or have you ever had any of the following:
  • Heart condition or heart surgery?
    Yes
    No
  • Kidney failure or transplant?
    Yes
    No
  • Cancer or a brain or spinal tumour?
    Yes
    No
  • A mental illness which has required psychiatric or inpatient treatment?
    Yes
    No
  • Diabetes?
    Yes
    No
  • Have you received or been advised to have any medical investigations, scans or blood tests in the last 5 years?
    Yes
    No
  • Have you been referred to, or been to see, any medical practitioner other than your GP in the last 5 years?
    Yes
    No
  • Are awaiting a consultation with a specialist for any medical condition?
    Yes
    No
  • Have you used any medication which requires a prescription from a doctor in the last month?
    Yes
    No
  • Before the age of 65 has more than one member of your immediate family been diagnosed with cancer, heart disease, stroke, or any neurological complaint?
    Yes
    No
OR
OR



Address

Policy Holder 1




** Your details will not be passed onto third parties or used for marketing purposes.
SUBMIT YOUR APPLICATION