Membership Application

IMPORTANT NOTES – PLEASE READ BELOW BEFORE COMPLETING THIS FORM

When you complete this application form you should be aware that you must disclose all material facts. A material fact is any information that is likely to affect our decision to accept your application or the amount of subscription you pay. You are obliged to disclose this type of information to us, even if the application form has not asked specific questions about it. So, if you are unsure whether a fact is material or not, you must include it on your application form. Failure to disclose all material facts could result in your application being rejected, or you could find that your policy is invalid when you make a claim and no benefit will be payable. We will rely on what you tell us and you must not assume that we will clarify or confirm any information that you have provided with your medical attendants. Any rates, subscriptions or benefits indicated by the Society in any literature are based on an application being accepted on normal terms. The Society reserves the right to decline membership or offer membership on different terms based on information shown on the application form or received from other sources.

Application Form

Section 1

(i) PERSONAL DETAILS

(ii) EMPLOYMENT DETAILS

Surname

Profession or Occupation (please be precise)

Title

For how long have you been so employed?

If other, Please state

Are you self employed? (please tick)

Yes

Forenames

if yes, how long for?

Private Address

What is your average weekly gross income? (Net pre-tax earnings if self-employed)

Postcode

In the event of incapacity, for how long would you receive income or benefit from any source and at what rate?

Telephone

For how many weeks? If more than one source, give full details

If employed are you on a fixed term contract?

Yes

Business Address

If so, please provide the date the contract ends?

Business Postcode

(iii) OTHER INSURANCES

Business Telephone

For a life, accident or sickness policy, have you ever been refused or offered insurance on terms other than standard?

Yes

Business Email

If yes, please give details here or separately

Date of birth

Do you have, or have you applied for sickness or accident insurance here or elsewhere? (Please tick)

Place of birth (Town) (County)

a) I have sickness or accident insurance with dg mutual

Yes

If your place of birth is not in the UK, how long have you been a UK resident?

b) I have sickness or accident insurance elsewhere

Yes

Have you ever resided outside the UK? (please tick)

Yes

c) I have previously applied for sickness or accident insurance with dg mutual

Yes

Have you any prospect or intention of residing outside the UK? (please tick)

Yes

d) I have previously applied for sickness or accident insurance with another company

Yes

Do you intend to engage in flying other than as a fare paying passenger? (please tick)

Yes

If yes, please give details here or separately
Name of Company or Society

Please list any competitive sports, hobbies or activities likely to cause injury in which you currently or intend to participate.

Weekly Benefit

How did you hear about dg mutual?

Deferred Period

If referred by a dg mutual member, Please state the member’s name

If you have this type of cover elsewhere will it continue?

Yes

If in a journal, Please state which publication

Section 2

HEALTH DETAILS

Please answer every question. If you answer YES to any question please use the space provided at the bottom of Section 2 to give full details, including dates, time off work and current prognosis.

Have you ever had :-

a. Name and address of your Doctor

1. Anxiety, stress, depression, fatigue, breakdown or counselling?

Yes

b. How long have you been registered with your Doctor?

2. Back, neck or shoulder pain, or disc problems?

Yes

If less than 6 months, please provide your previous Doctor's details

3. Arthritis, joint, bone, ligament or muscle problems?

Yes

c. Please state your weight?

4. Chest, lung, breathing problems including asthma and bronchitis?

Yes

d. Has there been any increase or loss in your weight in the last year?

Yes

e. Please state your height?

5. Heart disease, including heart attack, angina, chest pains or heart defects?

Yes

f. Have you ever smoked?

Yes

6. Digestive system, stomach, bowel or liver problems?

Yes

If yes, how many per day?

7. Any disorder of the genito-urinary system, kidney, bladder or prostate?

Yes

If you no longer smoke, when did you give up?

8. Blood pressure problems or blood disorders?

Yes

g. What is your average weekly consumption of alcohol in units? (1 pint beer = 2 Units / 1 glass wine/measure of spirits = 1 Unit)

9. Skin disorders or allergies?

Yes

h. Have you been advised to reduce your alcohol intake?

Yes

10. Eye or ear problems? (You can ignore sight problems corrected by glasses or contact lenses)

Yes

i. Are you currently undergoing any treatment or awaiting any referral, tests, results or surgery?

Yes

11. Diabetes or impaired glucose intolerance?

Yes

j. Are you at present suffering from any disease, disorder or disability?

Yes

12. Debility, post viral/chronic fatigue syndrome or ME?

Yes

k. Have you ever taken or are you currently taking any drugs NOT prescribed by a doctor?

Yes

13. Migraine attacks, fits, faints, blackouts or paralysis or any disorder of the central nervous system?

Yes

l. Have you consulted any other health professional such as a Chiropractor or Osteopath?

Yes

14. Hernia, haemorrhoids or varicose veins?

Yes

m. Have you ever tested positive for HIV/Aids, Hepatitis B or C or any other sexually transmitted disease?

Yes

15. Tumours, cancers or growths
(including leukaemia or Hodgkin’s disease)?

Yes

16. Any gynaecological, menstrual, uterine or breast disease/disorder?

Yes

17. Any other illness, disability, mental or physical impairment or previous consulation that might be relevent to this application?

Yes

If you have answered YES to any of the questions in Section 2 please give full details.

Please note that failure to disclose relevant information could mean that we will reject your claim and your policy will be cancelled.

Question Ref

Details

Dates

Question Ref 1

Details 1

Dates 1

Question Ref 2

Details 2

Dates 2

Question Ref 2

Details 3

Dates 3

Question Ref 4

Details 4

Dates 4

Please give details below of the last time you sought medical advice if it was within the last three years (including the name and address of the medical practitioner if different to that given at 2a). Show dates, nature of incapacity and indicate any time away from work.

Please provide details if any of your immediate family have been diagnosed with or died from any of the following diseases before the age of 65.