Pre Sale Underwriting Capture

Pre-sale Underwriting Capture Form

Complete the form
Press Send
Our Pre-sale Underwriting Team will email you an indication of terms

Be advised : If you need to disclose more than five Customer Medical Conditions or five Family History Conditions, call Pre-sale Underwriting on:

0370 333 3699

Monday to Thursday (9am to 5pm)
Friday (9am to 4pm).

Occupation Guide (To help with Question - Customer's Occupation title)

* Required

Your details

Your Name (As the adviser not the customer) *

Your company *

Your email *

Product details

Products required * Life Cover Critical Illness Cover (CIC) Critical Illness Cover Extra (CICX) Income Protection Benefit (IPB)

Sum Assured - Life Cover

Term - Life Cover

Sum Assured - CIC

Term - CIC

Sum Assured (CICX)

Term - CICX

Monthly Benefit - IPB

Term - IPB

Reason for cover

Customer details

Customer's Occupation title

Age Next Birthday *

Gender *

Female

Male

If your client is pregnant, please confirm their pre-pregnancy weight

Height *

Weight *

During the last 12 months have you smoked any cigarettes, cigars, a pipe (including shisha/hookah), used vapes, e-cigarettes, or nicotine replacements? you need to answer yes even if the product used did not contain any nicotine

Yes

How many per day? (If you do not smoke cigarettes daily, then please enter 0) *

Does your customer drink alcohol?

Yes

How many drinks per day? (For example a drink is a glass of wine, or a glass or bottle of beer) *

Has your customer ever been advised by a medical professional reduce their alcohol consumption because they were drinking too much, attended or been advised to attend an alcohol support group or seen an alcohol support specialist?

Yes

Unfortunately we will be unable to consider any cover based on this answer

During the last 10 years, has your client used any recreational drugs?

Yes

Drugs to consider: Any recreational drugs for example, cocaine, ecstasy or amphetamines, heroin or opioids? - Anabolic steroids not prescribed by a doctor? - Psychoactive substances including drugs previously known as ‘legal highs’? - Anabolic steroids (or any performance enhancing drugs) not prescribed by a doctor?

Been addicted to, misused or overused any medication whether prescribed by a doctor or not? - Cannabis (unless prescribed by a health professional) - You don't need to answer this question ‘Yes’ if you use or have used CBD oil only

We’ll only use the answer to the above question to assess your client’s application and at claim stage. Therefore there are no ‘legal implications’ in answering yes to this question.

Please provide details of what was used, how frequent and date of last use *

Is your customer resident in the UK (excluding the Channel Islands and the Isle of Man)? *

Yes

Unfortunately we will be unable to consider any cover based on this answer

For your client to be classed as a UK resident, they must be currently living in the UK and have done so for at least 183 days in the last tax year.

During the last 5 years has your customer spent more than 90 consecutive days in Africa, the Caribbean, Russia, Thailand or Ukraine?

Yes

Provide country of travel, purpose and duration of stay *

During the next 2 years does your customer intend to spend more than 30 consecutive days outside the UK? (Please ignore travel as a member of the Armed Forces)

Yes

Provide country of travel, purpose and duration of stay *

Customer Medical Conditions

Does your customer have any medical condition to disclose?

Yes

Name of condition *

Date of diagnosis *

If cancer, what stage and grade *

Current and past medication or treatment including dates and dosage *

Latest readings (if applicable to this condition *

What were the symptoms and their dates and duration *

Any hospital visits or inpatient treatment, including dates *

Any ongoing follow ups, appointments plus confirmation of date of discharge if applicable *

Is there another condition to disclose? (2) *

Yes

Name of condition *

Date of diagnosis *

If cancer, what stage and grade *

Current and past medication or treatment including dates and dosage *

Latest readings (if applicable to this condition) *

What were the symptoms and their dates and duration *

Any hospital visits or inpatient treatment, including dates *

Any ongoing follow ups, appointments plus confirmation of date of discharge if applicable *

Is there another condition to disclose? (3) *

Yes

Name of condition *

Date of diagnosis *

If cancer, what stage and grade *

Current and past medication or treatment including dates and dosage *

Latest readings (if applicable to this condition) *

What were the symptoms and their dates and duration *

Any hospital visits or inpatient treatment, including dates *

Any ongoing follow ups, appointments plus confirmation of date of discharge if applicable *

Is there another condition to disclose? (4) *

Yes

Name of condition *

Date of diagnosis *

If cancer, what stage and grade *

Current and past medication or treatment including dates and dosage *

Latest readings (if applicable to this condition) *

What were the symptoms and their dates and duration *

Any hospital visits or inpatient treatment, including dates *

Any ongoing follow ups, appointments plus confirmation of date of discharge if applicable *

Is there another condition to disclose? (5) *

Yes

Name of condition *

Date of diagnosis *

If cancer, what stage and grade *

Current and past medication or treatment including dates and dosage *

Latest readings (if applicable to this condition) *

What were the symptoms and their dates and duration *

Any hospital visits or inpatient treatment, including dates *

Any ongoing follow ups, appointments plus confirmation of date of discharge if applicable *

Is there another condition to disclose? (6) *

Yes

For more than 5 conditions please call the Pre-sale Underwriting Team to provide an indicative decision.

Call on:

0370 333 3699

We're available 9.00am to 5.00pm Monday to Friday.

Family History

Have any of your customer's biological parents, brothers or sisters been diagnosed before the age of 60 with any of the below conditions?

Yes

Conditions:

Heart attack, Angina, Stroke or Type 2 Diabetes, Cancer, Cardiomyopathy (primary disorder of the heart muscle), Multiple Sclerosis, Myotonic Dystrophy, Polyposis coli (Familial adenomatous), Polycystic Kidney Disease, Motor Neurone Disease, Huntington's Disease, Parkinson's Disease, Alzheimer's Disease, and any other condition that runs in your family and which you're receiving regular follow up or screening for.

Name of Condition *

Age of relative(s) at diagnosis *

Do you want to add another relative / condition ? (2) *

Yes

Name of Condition *

Age of relative(s) at diagnosis *

Do you want to add another relative / condition ? (3) *

Yes

Name of Condition *

Age of relative(s) at diagnosis *

Do you want to add another relative / condition ? (4) *

Yes

Name of Condition *

Age of relative(s) at diagnosis *

Do you want to add another relative / condition ? (5) *

Yes

Name of Condition *

Age of relative(s) at diagnosis *

Do you want to add another relative / condition ? (6) *

Yes

For more than 5 family conditions please call the Pre-sale Underwriting Team to provide an indicative decision.

Call on:

0370 333 3699

We're available 9.00am to 5.00pm Monday to Friday.