Insurance Health Details

Name*

First Last

Email*

What is your height? (cm)

What is your weight? (kg)

If your weight has varied by more than 10kgs in the past 12 months please provide reasons in the box below.

Do you smoke cigarettes or tobacco?

If yes, please provide details of how much you smoke per day.

Are you currently on any medication?

If yes, please provide details of the reason, type of medication and the amount you take daily.

Do you currently have any back, joint or mental health conditions?

If yes, please provide as much detail as possible in the box below.

Are you currently under the care or treatment of a specialist?

If yes, please provide as much detail as possible in the box below.

Do you currently have any medical tests or investigations pending or recommended by your GP or specialist?

If yes, please provide as much detail as possible in the box below.

Please provide details in the box below of any other illnesses or injuries that you feel an insurer should know about when assessing an insurance application.

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