Health Questionnaire - Connect Mortgage Services

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Full Name *

Date of Birth *

Email *

Phone Number *

Smoker Status *

Average Alcoholic Drinks Per Week

Includes a pint of beer/cider, average sized glass of wine or a single measure of spirits.

Height

Enter in either feet & inches or centimetres.

Weight

Enter in either stones & pounds or kilograms.

Drinking Habits *

Do you already have any Life Cover, Critical Illness / Serious Illness or Income Protection Cover? *

Including this application, will the total amount of Life Cover you have for all purposes exceed £2 million, or £800,000 for Serious Illness / Critical Illness cover? *

Employment Status *

Yearly Income Amount

Main Occupation

Do you work in or with the Armed Forces or Reserve Forces? *

Apart from commuting between your home and a fixed place of work, does your job involve driving more than 25,000 miles per annum? *

Do you work less than 16 hours per week? *

If you are unemployed, a student, a houseperson, retired or a pensioner then answer "No".

In the next 12 months, do you intend spending more than 4 weeks overall in the Middle East, Africa, Central or South America, Asia (excluding Japan, Hong Kong and Singapore), Ukraine, Russia or New Guinea? *

In the last 3 years have you spent more than 3 consecutive months in Africa, Thailand or the Caribbean? *

Do you take part in or intend to take up any hazardous activities? *

Examples include aviation, parachuting, skydiving, hang-gliding, water sports, diving, mountaineering, caving, bouldering, motor sports, or extreme sports. One day experiences or taster sessions can be ignored.

Have you ever been advised to reduce your alcohol intake because you were drinking too heavily? *

Have you attended or been advised to attend a hospital or medical facility due to an injury, illness or incapacity whilst under the influence of alcohol? *

Have you used or been referred to a specialist support service or counsellor regarding alcohol intake? *

Have you been advised to have or have had a scan, biopsy, blood test or other investigations to check your liver is functioning correctly? *

Additional Information

If you answered Yes to any questions, provide dates of diagnosis, medication/action taken, final diagnosis and any time off work.

In the last 10 years, have you used recreational drugs? *

Examples include cannabis, amphetamines, cocaine, ecstasy, hallucinogens, opiates, solvents or anabolic steroids.

In the last 10 years, have you attended or been advised to attend a hospital or medical facility due to an injury, illness or incapacity whilst under the influence of drugs? *

In the last 10 years, have you used or been referred to a specialist support service or counsellor in relation to drug intake? *

In the last 10 years, have you misused, overused or been addicted to any medication, whether prescribed by a doctor or not? *

In the last 5 years, have you received a penalty due to drink driving? *

In the last 5 years, have you received a penalty due to drug driving? *

Before the age of 60, have any members of your immediate family had any of the following medical conditions? *

Breast, ovarian, prostate, colon or bowel cancer, heart attack, angina, stroke, cardiomyopathy, diabetes, multiple sclerosis, muscular dystrophy, Parkinson's, dementia / Alzheimer's disease, Huntington's, motor neurone disease or polycystic kidney disease.

Are there any other conditions that run in your family that you have had, or been advised to have ongoing screening / monitoring for? *

Your Health

Have you ever had or do you currently have cancer, leukaemia, Hodgkin's disease, lymphoma, or a brain or spinal tumour? *

Have you ever had or do you currently have heart disease or disorder, including heart attack, angina, cardiomyopathy, heart murmur, heart surgery or procedure, palpitations, irregular heartbeat or chest pain? *

Have you ever had or do you currently have a stroke, transient ischaemic attack (TIA), brain haemorrhage or permanent brain injury through an accident? *

Have you ever had or do you currently have multiple sclerosis, optic neuritis, epilepsy, paralysis, muscular dystrophy, Parkinson’s disease, dementia or Alzheimer’s disease, cerebral palsy, motor neurone disease or any disorders of the brain or nerves? *

Have you ever had or do you currently have a mental health problem where hospital treatment or a referral to a psychiatrist or hospital clinic has been advised? *

Have you ever tested positive for HIV, Hepatitis B or C, or are you awaiting the results of such a test? *

Apart from any condition already disclosed, have you had diabetes, raised blood sugar, pre-diabetes or impaired glucose tolerance (IGT) in the last 5 years? *

Health Details

Please provide more detail on any Yes answers, including medication, dates, diagnosis, treatment, and time off work if applicable.

If you answered Yes to any of the Health questions, please provide medication, how long you have suffered, when you were last affected, when you last visited your doctor, whether you had time off work, and any other relevant detail.

Your Health in the last 5 years

Apart from any condition already disclosed, have you had any of the following in the last 5 years:

• Diabetes, raised blood sugar, pre-diabetes or Impaired Glucose Tolerance (IGT)? *

• Raised blood pressure or raised cholesterol, Deep Vein Thrombosis, disease, or disorder of the blood vessels including the aorta and arteries of the leg or neck or any condition affecting the blood such as anaemia or thalassemia? *

• Numbness, tremor, tingling, pins and needles, dizziness, facial pain or visual disturbance including blurred or double vision? *

• Seizures, fits, fainting, blackouts or memory loss? *

• Any disorder of the digestive system, liver, stomach, oesophagus, pancreas, colon or bowel, including hepatitis, colitis, Crohn’s disease, irritable bowel syndrome, bleeding or stomach ulcers? *

• Any disorder of the kidneys, bladder or prostate, including blood or protein in the urine or urinary tract infection? *

• Any mental health problem including depression, stress, anxiety, panic attacks or eating disorder that has required treatment, consultation with a health professional or time off work? *

• Post viral syndrome, continuous fatigue, tiredness, long/chronic covid, ME (Myalgia encephalon-myelitis) or fibromyalgia? *

• Any respiratory or lung disorder, including asthma, bronchitis, COPD (COAD), emphysema or sleep apnea? *

• Lump, cyst, growth or skin lesion of any kind, or a mole or freckle that has bled, become painful, itchy, changed colour, increased in size or that you have been advised to monitor (including photographic surveillance)? *

• Any pain or other problems relating to your back, neck, joints, bones or muscles including arthritis, ankylosing spondylitis, rheumatism or gout? *

• Any disorder of the eyes or ears, including blindness, deafness, problems with your sight or difficulty hearing? (conjunctivitis, sight problems fully corrected by glasses, contact lenses or laser eye treatment for short / long sight or cosmetic reasons, or simple earache or ear infections that have cleared up with no ongoing hearing loss can be ignored). *

• Any gynaecological disorder which has required regular follow up or referral to a specialist including abnormal cervical screening (smear tests), abnormal menstrual bleeding or breast conditions? Infertility treatment, Miscarriage / termination, uncomplicated pregnancy / caesarean section, thrush, routine scan / blood test for pregnancy, routine cervical screening/smear test (normal result), HRT (no investigations involved) can be ignored. *

• Required more than 2 weeks off work for any medical condition, illness or injury not already mentioned? (Please ignore flu or colds from which you've fully recovered and pregnancy where no complications were present). *

• Claimed compensation for any injury or illness or claimed on any other income protection policy or plan. *

Recent and Current Health

Apart from anything you have already told us about on this application, in the last 3 years have you:

• Been told to have any tests or checks - even if you're still waiting to have them or get the results? This may include blood tests, urine tests, x rays, scans, biopsies or using a camera inside your body. *

• Contacted or been referred to any medical professional other than your GP? This includes online or video appointments. *

• Had, or been told to have, any treatment, therapy or medication that lasted (or is expected to last) 4 weeks or more? *

Apart from anything already disclosed, in the last 3 months have you had a lump, growth, cyst or lesion that has grown or changed in appearance, blood in your urine, bleeding from the bowel, a change in bowel habit, or unexplained weight loss? *

Apart from anything already disclosed, in the last 3 months have you had any other symptom you are planning to consult a medical professional or therapist about? *

Health Details

Provide more detail on any Yes answers, including medication, dates, diagnosis, treatment, and time off work if applicable.

GP Information

Doctor's Address

Doctor's Name

Doctor's Number

Would you like to put this policy in trust? *

This means once the trust is set up, the named trustee will legally own your life insurance cover, meaning on a successful claim, the finances will be processed much quicker. This can also be a tax efficient way of going about things.

Bank Details

Account Holder Name *

Account Number *

Sort Code *

Preferred Payment Date (1-28) *

Name

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Email Address *

Phone Number

Please do not fill in this field.

Address

60 Sedlescombe Road North,

St Leonard’s on Sea

East Sussex,

TN37 7DT

Contact Us

Tel: 01424 395419

Email: info@connectmortgageservices.co.uk

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The guidance and/or advice contained within this website is subject to the UK regulatory regime, and is therefore targeted at consumers based in the UK.
Connect Mortgage Services Limited are an Appointed Representative of Prosper Home Loans. Connect Mortgage Services Limited are entered on the Financial Services Register https://register.fca.org.uk under reference 1005419.
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