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? *

What is your Date of Birth? *

Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Month January February March April May June July August September October November December

Year 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944

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? *

First Name

Last Name

What's your email address? *

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