Membership Application

IMPORTANT NOTES – PLEASE READ 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 being 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.

Surname

Title

Fornames

Gender

Private Address

Postcode

Telephone

Business Address

Postcode

Telephone

Date of Birth

Place of Birth (Town) (Country)

If your place of birth is not in the UK, how long have you resided here?

Have you ever resided or have any prospect or intention of residing outside the British Isles? (please tick) Have you ever resided or have any prospect or intention of residing outside the British Isles? (please tick) Yes No

Do you intend to engage in flying other than as a fare paying passenger? (please tick) Do you intend to engage in flying other than as a fare paying passenger? (please tick) Yes No

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

Profession or Occupation (please be precise)

For how long have you been so employed?

Are you self employed? (please tick) Are you self employed? (please tick) Yes No

If yes, for how long?

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 (£) per week. If more than one source, give full details here or separately

If employed are you on a fixed term contract? If employed are you on a fixed term contract? Yes No

If so, please provide the date the contract ends

Have you ever been refused or offered insurance on terms other than standard, for a life, accident or sickness policy? Have you ever been refused or offered insurance on terms other than standard, for a life, accident or sickness policy? Yes No

If yes, please give details here or seperately

Name of Company or Society

Weekly Benefit

Deferred Period

If you have this type of cover elsewhere will it continue? If you have this type of cover elsewhere will it continue? Yes No

Name and address of your Doctor

How long have you been registered with your Doctor?

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

Please state your weight?

Has there been any increase or loss in your weight in the last year? Has there been any increase or loss in your weight in the last year? Yes No

Please state your height?

Have you ever smoked? Have you ever smoked? Yes No

If yes, how many per day?

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

Have you been advised to reduce your alcohol intake? Have you been advised to reduce your alcohol intake? Yes No

Are you currently undergoing any treatment or awaiting any referral, tests, results or surgery? Are you currently undergoing any treatment or awaiting any referral, tests, results or surgery? Yes No

Are you at present suffering from any disease, disorder or disability? Are you at present suffering from any disease, disorder or disability? Yes No

Have you ever taken or are you currently taking any drugs NOT prescribed by a doctor? Have you ever taken or are you currently taking any drugs NOT prescribed by a doctor? Yes No

Have you consulted any other health professional such as a Chiropractor Osteopath? Have you consulted any other health professional such as a Chiropractor Osteopath? Yes No

Have you ever tested positive for HIV/Aids, Hepatitis B or C or any other sexually transmitted disease? Have you ever tested positive for HIV/Aids, Hepatitis B or C or any other sexually transmitted disease? Yes No

Have you ever had:- Anxiety, stress, depression, fatigue, breakdown or counselling? Have you ever had:- Anxiety, stress, depression, fatigue, breakdown or counselling? Yes No

Have you ever had:- Back, neck or shoulder pain, disc problems? Have you ever had:- Back, neck or shoulder pain, disc problems? Yes No

Have you ever had:- Arthritis, joint, bone, ligament or muscle problems? Have you ever had:- Arthritis, joint, bone, ligament or muscle problems? Yes No

Have you ever had:- Chest lung, breathing problems including asthma and bronchitis? Have you ever had:- Chest lung, breathing problems including asthma and bronchitis? Yes No

Have you ever had:- Heart disease, including heart attack, angina, chest pains or heart defects? Have you ever had:- Heart disease, including heart attack, angina, chest pains or heart defects? Yes No

Have you ever had:- Digestive system, stomach, bowel or liver problems? Have you ever had:- Digestive system, stomach, bowel or liver problems? Yes No

Have you ever had:- Any disorder of the genito-urinary system, kidneys, bladder or prostate? Have you ever had:- Any disorder of the genito-urinary system, kidneys, bladder or prostate? Yes No

Have you ever had:- Blood pressure problems or blood disorders? Have you ever had:- Blood pressure problems or blood disorders? Yes No

Have you ever had:- Skin disorders or allergies? Have you ever had:- Skin disorders or allergies? Yes No

Have you ever had:- Eye or ear problems? (You can ignore sight problems corrected by glasses or contact lenses) Have you ever had:- Eye or ear problems? (You can ignore sight problems corrected by glasses or contact lenses) Yes No