Profession or Occupation (please be precise)
Title Dr Mr Mrs Miss Ms
For how long have you been so employed?
If other, Please state Are you self employed? (please tick)
if yes, how long for?
What is your average weekly gross income? (Net pre-tax earnings if self-employed)
In the event of incapacity, for how long would you receive income or benefit from any source and at what rate?
For how many weeks? If more than one source, give full details
Email If employed are you on a fixed term contract?
If so, please provide the date the contract ends?
Business Telephone For a life, accident or sickness policy, have you ever been refused or offered insurance on terms other than standard?
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
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 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 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.
How did you hear about dg mutual? Referred by a dg mutual member’ Website Facebook Twitter Email received Information in the post In a journal
If referred by a dg mutual member, Please state the member’s name If you have this type of cover elsewhere will it continue?
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.
a. Name and address of your Doctor 1. Anxiety, stress, depression, fatigue, breakdown or counselling?
b. How long have you been registered with your Doctor? 2. Back, neck or shoulder pain, or disc problems?
If less than 6 months, please provide your previous Doctor's details 3. Arthritis, joint, bone, ligament or muscle problems?
c. Please state your weight? 4. Chest, lung, breathing problems including asthma and bronchitis? d. Has there been any increase or loss in your weight in the last year?
e. Please state your height? 5. Heart disease, including heart attack, angina, chest pains or heart defects? 6. Digestive system, stomach, bowel or liver problems?
If yes, how many per day? 7. Any disorder of the genito-urinary system, kidney, bladder or prostate?
If you no longer smoke, when did you give up? 8. Blood pressure problems or blood disorders?
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? 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 Details Dates
Question Ref 1
Question Ref 2
Question Ref 2
Question Ref 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.