Do you smoke? (have you smoked tobacco or used nicotine products in the past 12 months?) *

Yes
No

How much cover are you looking for? *

How much do you want to pay each month? *

What is your Date of Birth? *

Do you wish to answer the medical questions? *

Yes
No

1a. Are you undergoing or awaiting any consultations, investigations, or test results with a GP or Specialist, for any medical condition that has not yet been formally diagnosed?; or b. In the last 12 months, have you had, been diagnosed with, received treatment for, or attended a consultation due to: heart disease, a stroke, cancer (or recurrence), chronic obstructive pulmonary disease/emphysema, or a terminal illness? *

Yes
No

2. In the last five years, have you had, been diagnosed with, received treatment for, or attended a consultation due to: heart disease, a stroke, cancer or chronic obstructive pulmonary disease/emphysema? *

Yes
No

What's your telephone number? *

What's your name? *

What's your email address? *

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