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LifeQuote Decision-in-Principle Data Capture Form
Page 1 of 48 October 16 – AL
Protection
Decision-in-Principle
LifeQuote Decision-in-Principle Data Capture Form
Page 2 of 48 October 16 – AL
Contents Check List
1. Adviser Information
Completed Yes / No Page 3
2. Provider Selection
Completed Yes / No Page 3
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
Completed Yes / No Page 8
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
Completed Yes / No Page 44
9. Residency & Overseas Travel
Completed Yes / No Page 45
10. Outcome: i. Summary
Completed Yes / No Page 46
11. Appendix i. Key Person
Completed Yes / No Page 47
LifeQuote Decision-in-Principle Data Capture Form
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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
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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
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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?
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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
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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
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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
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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
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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?
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?
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
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What do you estimate your client's flying hours will be in the next 12 months?
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?
How many flying hours does your client have?
What do you estimate your client's flying hours will be in the next 12 months?
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
If ‘Yes’, please give full details
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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
If ‘Yes’, please give full details
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
If ‘Yes’, please give full details
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.
Please confirm the average number of hours
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your client fly’s a year.
Paragliding
Is your client a member of the British Hang-gliding and Paragliding Association (BHPA)?
Yes / No
Please confirm the average number of hours your client fly’s a year.
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
If ‘Yes’, please give full details
Has your client ever taken part in a public display?
Yes / No
If ‘Yes’, please give full details
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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
If ‘Yes’, please give full details
Is your client a member of any caving clubs? Yes / No
If ‘Yes’, please give full details
Does your client ever cave or pothole alone? Yes / No
If ‘Yes’, please give full details
Has your client ever done, or do they intend to do, any of the following?
Single rope techniques Yes / No
If ‘Yes’, please give full details
Cave Diving Yes / No
If ‘Yes’, please give full details
Digging or exploring new mines Yes / No
If ‘Yes’, please give full details
Exploring abandoned mines Yes / No
If ‘Yes’, please give full details
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Has your client ever been involved in a rescue? Yes / No
If ‘Yes’, please give full details
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
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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
Professional/Sponsored Yes / No
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
If ‘Other’, please give further details
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.
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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
Professional/Sponsored Yes / No
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.
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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?
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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
If ‘Yes’, please give full details
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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
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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
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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
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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
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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?
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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
If ‘Yes’, please give full details
Is your client currently waiting for any investigation?
Yes / No
If ‘Yes’, please give full details
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
Can you give us any more information that you feel will help us to consider this enquiry further?
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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
If 'Yes', please give further details including dates (dd/mm/yyyy) and duration
Please provide any additional information about your client's condition that you feel will be
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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.
Can you give us any more information that you feel will help us to consider this enquiry further?
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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
If ‘No’, please give full details
Is your client currently receiving follow-up checks?
Yes / No
If 'Yes', please give the date next follow-up appointment (dd/mm/yyyy)
Can you give us any more information that you feel will help us to consider this enquiry further?
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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
Can you give us any more information that you feel will help us to consider this enquiry further?
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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
If 'Yes', please give full details and results.
Is your client currently getting any follow-up checks?
Yes / No
If 'Yes', please give full details and results.
If your client's checks are complete, please give us the date of their last check (dd/mm/yyyy)
Can you give us any more information that you feel will help us to consider this enquiry further?
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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.
Can you give us any more information that you feel will help us to consider this enquiry further?
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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
If 'Yes', please give further details
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
If 'Yes', please give further details
Is your client permitted to hold a UK driving licence?
Yes / No
If 'No', please give further details
Can you give us any more information that you feel will help us to consider this enquiry further?
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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
If ‘Other’, please give further details
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
If 'Yes', please give further details
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
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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
If 'Yes', please give further details
Has there been any recurrence of the symptoms?
Yes / No
If 'Yes', please give further details including dates (dd/mm/yyyy) and duration
Did the symptoms cause your client any incapacity or time off work?
Yes / No
If 'Yes', please give further details including dates (dd/mm/yyyy) and duration
Please provide any additional information about your client's condition that you feel will be helpful when assessing this enquiry
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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
If 'Yes', please give further details
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)?
Can you give us any more information that you feel will help us to consider this enquiry further?
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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
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 B
Has your client tested positive to Hepatitis B? 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 C +
Has your client tested positive to Hepatitis C+? 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 D
Has your client tested positive to Hepatitis D? 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 E
Has your client tested positive to Hepatitis e? Yes / No
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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?
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
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If 'No', please give full details
Can you give us any more information that you feel will help us to consider this enquiry further?
7.xv: Neurological Disorders
What is your client's current diagnosis? Please select
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
If 'Yes', please give further details including dates (dd/mm/yyyy) and duration
Has your client had time off work as a result of their condition?
Yes / No
If 'Yes', please give further details including dates
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(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
If ‘Yes’, please provide full details
Is your client having regular follow-up checks with their GP or at hospital?
Yes / No
If ‘Yes’, please provide full details
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
If ‘Yes’, please give full details
Has your client's urine checks always been normal?
Yes / No
If ‘No’, please give full details
Have your client’s biological parents, brothers or sisters died or suffered from heart disease,
Yes / No
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stroke, high blood pressure, and diabetes or kidney disease?
If ‘Yes’, please provide full details
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
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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
What is your client's current diagnosis? Please select
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
If 'Yes', please give further details
Does your client present any co-morbid diseases related to their current impairment?
Yes / No
If 'Yes', please give further details
Can you give us any extra information that will help us consider this enquiry further?
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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
Can you give us any more information that you feel will help us to consider this enquiry further?
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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
If 'Yes', please give further details
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
If 'Yes', please give further details
Can you give us any more information that you feel will help us to consider this enquiry further?
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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
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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
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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
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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
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relief