Membership Application


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



Are you self employed? (please tick)
If employed are you on a fixed term contract?


For a life, accident or sickness policy, have you ever been refused or offered insurance on terms other than standard?
Do you have, or have you applied for sickness or accident insurance here or elsewhere? (Please tick)
a) I have sickness or accident insurance with dg mutual
b) I have sickness or accident insurance elsewhere
Have you ever resided outside the UK? (please tick)
c) I have previously applied for sickness or accident insurance with dg mutual
Have you any prospect or intention of residing outside the UK? (please tick)
d) I have previously applied for sickness or accident insurance with another company
Do you intend to engage in flying other than as a fare paying passenger? (please tick)
If you have this type of cover elsewhere will it continue?
Section 2


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 :-

1. Anxiety, stress, depression, fatigue, breakdown or counselling?
2. Back, neck or shoulder pain, or disc problems?
3. Arthritis, joint, bone, ligament or muscle problems?
4. Chest, lung, breathing problems including asthma and bronchitis?
d. Has there been any increase or loss in your weight in the last year?
5. Heart disease, including heart attack, angina, chest pains or heart defects?
f. Have you ever smoked?
6. Digestive system, stomach, bowel or liver problems?
7. Any disorder of the genito-urinary system, kidney, bladder or prostate?
8. Blood pressure problems or blood disorders?
9. Skin disorders or allergies?
h. Have you been advised to reduce your alcohol intake?
10. Eye or ear problems? (You can ignore sight problems corrected by glasses or contact lenses)
i. Are you currently undergoing any treatment or awaiting any referral, tests, results or surgery?
11. Diabetes or impaired glucose intolerance?
j. Are you at present suffering from any disease, disorder or disability?
12. Debility, post viral/chronic fatigue syndrome or ME?
k. Have you ever taken or are you currently taking any drugs NOT prescribed by a doctor?
13. Migraine attacks, fits, faints, blackouts or paralysis or any disorder of the central nervous system?
l. Have you consulted any other health professional such as a Chiropractor or Osteopath?
14. Hernia, haemorrhoids or varicose veins?
m. Have you ever tested positive for HIV/Aids, Hepatitis B or C or any other sexually transmitted disease?
15. Tumours, cancers or growths
(including leukaemia or Hodgkin’s disease)?
16. Any gynaecological, menstrual, uterine or breast disease/disorder?
17. Any other illness, disability, mental or physical impairment or previous consulation that might be relevent to this application?
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
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.