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BROCHURE

STELLAR HEALTH QUESTIONNAIRE

ADVISED NON ADVISED

ISAAVAILABLE WITH ISA

ISA

ADVISED NON ADVISED

ISA

AVAILABLE WITH ISA

ISA

WITHOUT ISA

ISASUPPLEMENTARY APPLICATION FORM

STELLAR HEALTH QUESTIONNAIRE

The information provided in this document is being obtained solely for use by our insurer, Omnilife Insurance Company. Stellar Asset Management Limited will retain a copy of this questionaire on file but will not use the data provided in any way.

1. Your Details (USE BLOCK CAPITALS)

Title: (Mr/Mrs/Miss/Ms etc)

Forename(s)

Surname:

Gender Male Female Date of birth D D M M Y Y Y Y

Marital status Married Single Divorced Widow

Home phone

Mobile phone

Email address

Address

Postcode

2. GP Details (USE BLOCK CAPITALS)

Name

Address

Postcode

Telephone:

Have you registered at this surgery within the last six months? Yes see below No

If Yes, please give your previous GP’s name and address

3. Occupation Details (USE BLOCK CAPITALS)

What is your occupation title?

Would you describe your duties as

Office-Based/Clerical Mobile/Sales orientated Light manual Heavy manual

If you drive to perform your duties (not including to and from work) please express as percentages the proportion of your time spent

Driving % Office based %

STELLAR HEALTH QUESTIONNAIRE ✶ 03

5. General Fitness and Personal Lifestyle

What is your weight? Kilograms or Stones and Pounds

Has your weight changed by more than two stones (or 1.3Kg) in the last two years? Yes No

What is your height? Metres or Feet and Inches

What is your waist measurement? Cm or Inches

What is the typical weekly alcohol consumption? Beer, Lager or Cider (<4.5% vol) PINTS Wine (glass) 175Ml

Beer, Lager or Cider (>4.5% vol) PINTS Spirits (measure) 35Ml

Teetotal YES NO

Have you ever been medically advised to reduce your alcohol consumption? YES NO

If Yes, please advise when this advice was given and what was your alcohol consumption at the time?

Beer, Lager or Cider (<4.5% vol) PINTS Wine (glass) 175Ml

Beer, Lager or Cider (>4.5% vol) PINTS Spirits (measure) 35Ml

What was your daily tobacco consumption in the last 12 months?

None Cigarettes Cigars Pipe tobacco

Have you ever tested positive, been treated for, or are waiting for results relating to any of these conditions?

HIV* YES NO

Hepatitis B YES NO

Hepatitis C YES NO

Any other sexually transmitted diseases YES NO

If Yes, please provide full details

*If the result is negative, the fact that an HIV test has been conducted, will have no effect on your acceptance terms for insurance.

4. Travel Details (USE BLOCK CAPITALS)

We do not need to know about holidays lasting less than one month or business trips lasting less than one week to any of the following countries

AUSTRALIA BELGIUM CANADA CHANNEL ISLANDS DENMARK FINLAND FRANCE

GERMANY GREECE HOLLAND LUXEMBOURG NEW ZEALAND ISLE OF MAN ITALY

PORTUGAL SWEDEN SPAIN USA REPUBLIC OF IRELAND UK

In the last five years, have you visited, worked in or travelled to a country NOT listed above? Yes No

If Yes, please give details below

Country Exact location

Date arrived Length of stay

Do you intend to visit, work in or travel to a country not listed above? If Yes, please give details below

Country Exact location

Date arrived Length of stay

04 ✶ STELLAR HEALTH QUESTIONNAIRE


5. General Fitness and Personal Lifestyle continued

Within the last five years, have you been exposed to the risk of HIV infection? YES NO

(HIV infection can be caught through unsafe sex, intravenous drug use or through surgery or blood transfusion outside the European Union)


6. Medical and Personal Sickness Absence details

Have you ever been absent from work for more than two consecutive months because of an accident or sickness?

If Yes, please provide full details YES NO

In the last three years, how many days in total have you been absent from work because of an accident or sickness? DAYS

In the last three years, have you been absent from work because of an accident or sickness for a period of more than one week?

If Yes, please provide full details YES NO

How many times have you consulted your General Practitioner in the past twelve months?

Please confirm whether you have had in the past or currently have any of the following

1. Cancer, Leukaemia, Hodgkin’s disease, Lymphoma, Brain or Spinal tumour? YES NO

2. A lump, growth of any kind, a freckle or mole(that has bled, changed colour, become painful or increased in size)? YES NO

3. High blood pressure or raised cholesterol? YES NO

4. Brain Haemorrhage, Stroke, brain injury through accident, or any other possible brain disorder, nerves or spinal cord (symptoms such as seizures, fits, dizziness, fainting or blackouts) ? YES NO

5. Heart attack, palpitations, chest pain, heart murmur, angina, any disease or abnormality of the heart, valves or veins? YES NO

6. Parkinson’s disease, Multiple Sclerosis, paralysis, epilepsy, Alzheimer’s disease, dementia or cerebral palsy? YES NO


7. Arthritis, neck, spine or joint disorder (including slipped disc, sciatica, back, neck, shoulder or knee pain or gout)? YES NO

8. Numbness, loss of feeling or tingling of the face or limbs, or temporary loss of muscle strength? YES NO

9. Asthma, bronchitis, emphysema or any other respiratory condition? YES NO

10. Kidney, bladder or any disorder of the genito-urinary system? YES NO

11. Liver, pancreas, digestive system or bowel disease or disorder (including hepatitis, colitis, gastric or duodenal ulcers or Crohn’s disease) ?

YES NO

12. Thyroid disorder? YES NO

13. Diabetes (including sugar in the urine)? YES NO

14. Blood disorder or anaemia? YES NO

15. Disorder of the ears? YES NO

16. Disorder of the eyes ( including blurred vision or optic neuritis)? YES NO

17. Any form of mental or nervous disorder (including anxiety, depression, stress, or nervous breakdown) or have you ever been prescribed anti-depressants or tranquilisers?

YES NO

If Yes has been ticked to any of the questions (1 to 17) please provide full detail below

Date symptoms started Day Month Year

Condition

Date symptoms ceased Day Month Year

Treatment


Condition


Treatment


Condition


Treatment


7. Sports & Hobbies

Do you take part in, or intend to take part in any hazardous sports? YES NO

If Yes, what is the sport

How often do you take part ( e.g. how many annual dives, climbs, races or flying hours)?

Where do you perform / undertake this activity (i.e. caves, mountains)?

Do you belong to any associated professional sporting bodies, or club relating to this activity? YES NO

What is your level of experience (e.g. how many years have you been undertaking this activity, what qualifications or licence do you hold)? YEARS

Qualifications or licence

What is the extent of this activity ( e.g. maximum height or depth reached, event or competition taken part in)?

Do you exercise regularly or take part in a sport that is not covered in the above questions ( e.g. in the last year, have you regularly taken exercise like gym or running etc or played football, rugby etc)?

YES NO

If Yes, please provide full details and how often you undertake it

8. Other insurance details

Have you ever been accepted for any life assurance, critical illness or income protection cover on special terms, or been refused cover by an insurer?

YES NO

If Yes, please provide full details below

Decision

Cover type

Date of Decision D D M M Y Y Y Y

In the last three years. have you had your urine or blood tested or had an ECG or x-ray or any other specialist test? YES NO


Have any of your parents, brothers or sisters, before the age of 65, died from, or suffered from heart disease, a stroke, high blood pressure, diabetes, kidney disease, cancer, multiple sclerosis, nervous disorder, paralysis or any hereditary disorder?

YES NO

If Yes, please provide full details below

Relative Age at diagnosis

Condition

As part of your employment benefits, are you required to attend regular medical examinations? YES NO

If Yes, and this examination was done in the last two years, please provide a contact name and address below, so a copy can be obtained. By doing this we may be able to avoid asking you to attend a further examination for us:

GP’s name & address (if different to box 2)

Postcode

9. Declaration & Consent

Please read the following notes carefully, they outline your statutory rights relating to the processing and use of information relating to your application. The references to “we” or “us” refer to Omnilife Insurance Company and not Stellar Asset Management.

How reports will be requested about your medical history

It may be necessary for us to ask any doctor who has attended to you to provide us with a medical report. In requesting this evidence, we shall always comply with the relevant law that sets out your statutory rights.

The acts that are relevant to obtaining this kind of medical report in the UK (except the Channel Islands) are the Access to Medical Reports Act 1988, the Access to Personal File and Medical Reports (Northern Ireland) Order 1991 and the Access to Health Records and Reports Act 1993 (Isle of Man). The Data Protection Act 1998 also governs the handling of medical reports.

We require your written consent to obtain a report. If you consent you can specify if you want to see the report before the doctor sends it to us. If you do want to see the report before it is sent to us, we shall inform the doctor who will hold the report for 21 days to allow you to see it. If you do see it before it is sent to us, the doctor will only release it with your permission. You can ask the doctor to amend anything in his report that you consider is incorrect or misleading.

The doctor is not abliged to let you see any part of the report that, in his opinion may harm your physical or mental health, or that of others, or that indicates the doctor’s intentions towards you. If the report reveals information about someone else who has supplied information about you, other than information from another health professional involved in your care, the doctor may only release it to you with that person’s consent. If this is the case, the doctor must notify you and you will be limited to seeing any remaining part of the report. If the whole report is affected, he must not send it to us unless you give your consent.

How information relating to you will be processed

We will hold all information relating to you (including medical reports) electronically and/or in a manual system. All information will be processed fairly and lawfully in accordance with the principles of the Data Protection Act 1998.

Information may be shared with third parties for purposes in relation to the application, for validation purposes and for other lawful purposes. These third parties (who may be situated either within or outside the European Economic Area) may include Reinsurers, Underwriters, the Financial Conduct Authority, the Financial Ombudsman, medical agencies, other insurance companies and agents. By signing this application, you agree that we may share information relating to you.

Medical information relating to you will not be shared with anyone other than you without your written consent. This includes your legal and financial advisers, your employer, your spouse or dependants. In order to administer the policy, non-medical information about you may be discussed with your financial adviser and your employer.

Declaration & Consent

I declare that to the best of my knowledge and belief that the information given above is true and complete in every respect and that I have not withheld any material information that may influence the assessment or acceptance of this proposal. I understand that if I have given incomplete or false information, Omnilife Insurance Company may change the underwriting terms, decline my claim or withdraw my cover.

I have read and understood my statutory rights concerning the processing and use of information relating to my application as set out in this form.

I consent to Omnilife Insurance Company seeking:-

Information from my medical records from any doctor who has attended me and I authorise the transfer of this information.

Information from any insurance office to which application has been made on my life and I authorise the transfer of this information.

Information concerning this application, including but not limited to health information, from any third party and I authorise the transfer of this information.

10. Please read and tick one of these boxes

I DO NOT WISH to see the report before it is sent to Omnilife Insurance Company

I WISH to see the report before it is sent to Omnilife Insurance Company

11. Finally, please read and tick BOTH boxes to confirm your understanding

I consent to Omnilife Insurance Company confirming the underwriting decision, including any exclusion wordings or other special terms, to the policyholder’s financial adviser.

I authorise Omnilife Insurance Company to release information, including but not limited to health information to my doctors, to doctors or specialists appointed by Omnilife Insurance Company in relation to my application, and to any third party who requires this information for legal purposes.

Your full name

Your Signature

Date D D M M Y Y Y Y


STELLAR ASSET MANAGEMENT LIMITED Kendal House 1 Conduit Street, London W1S 2XAt 020 3195 3500 e [email protected] www.stellar-am.com

Authorised and Regulated by the Financial Conduct Authority

achb brochure - stellar · pdf filebrochure stellar health questionnaire brochur e eabrochur...

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