PROTECT

Health & Lifestyle Disclosures
...helping ME protect you

In order to find the right cover for you, we need to know a bit of information about your health & lifestyle and work & family history.

Please complete this form as fully and honestly as possible as incorrect information could invalidate and policy claim.

PROTECTING YOUR HOME.

Ensuring my mortgage is paid off in the event of my death Ensuring my spouse can remain in the property mortgage free should anything happen to me Having sufficient means to remain in my home in the event I am diagnosed with a critical illness

PROTECTING YOUR FAMILY.

Ensuring my family receive a lump sum to pay bills in the event of my death Ensuring me and my family are not financially affected in the event I am diagnosed with a critical illness Ensuring my family have a regular payment to replace your income in the event of your death

PROTECTING YOUR INCOME.

Ensuring I can still afford your bills in the event of your being off work sick, even after my sick pay has ran out Ensuring I am able to maintain your lifestyle in the event of you becoming seriously unwell (Self Employed) Ensuring my business is still able to function in the event of myself or a key person passing away

AGREEMENT TO PROCEED

By ticking this box you agree to the following statement and how we will use the inormation you supply via this form.

On 25th May 2018 a change in the law took effect which impacts how businesses handle your sensitive information with certain providers .

The information you supply will be kept secure in accordance with General Data Protection Regulation (GDPR). Upon asking us to act on your behalf, we will share this information with protection and life insurance providers in order to find you the most appropriate product

You can find details of our Privacy Policy in the footer of our webpage.

Title

First Name

Middle Name(s)

Surname

Date of Birth

Gender

Male Female

Best Contact Number

Email

Doctors Surgery Name

Doctors Name

Surgery Address 1

Surgery Address 2

Surgery Post Code

Surgery Phone Number

Your Height

Weight

Smoker Status

Alcohol Consumption

Have you been advised to reduce of stop your alcohol consumption by a medical professional?

No Yes

Please give details

In the next 12 months do you plan to live or work abroad?

No Yes

Please give details

Do you take part / intend to take part in any of the following hazardous activities

Please provide any further relevant information

COVID 19 - In the last 30 days have you had a new or unexplained continuous cough, fever, high temperature, loss of smell or taste?

No Yes

In the last 30 days have you tested positive for, or been diagnosed with coronavirus/(COVID-19)?

No Yes

In the last 14 days have you been self-isolating or been advised you should?

No Yes

In the last 14 days have you had direct contact with someone who has been diagnosed with, or suspected of having coronavirus/(COVID-19)?

No Yes

Your Occupation

Occupation Type

Do you work under the following conditions?

Working outside at heights above 12m (40ft) Mining, tunneling of quarrying Oil or natural gas production Fishing or merchant marine Driving (not including commuting to and from work) General labouring or use of heavy machinery Aviation Diving Armed forces (including reserves)

Please provide any relevant information

HIV/AID: Have you ever tested positive for HIV hepatitis B or C or awaiting results of such a test?

No Yes

If you answered "YES" please give details

Within the last 5 years have you been exposed to the risk of an HIV infection?

No Yes

If you answered "YES" please give details

Within the last 5 years have you tested positive, or been treated, for any disease which is transmitted sexually?

No Yes

If you answered "YES" please give details

Have you ever taken or injected recreational drugs, anabolic steroids or prescription drugs not prescribed to you by a doctor/?

No Yes

If you answered "YES" please give details

Angina, heart attack, stroke, transient ischaemic attack (TIA), brain hemorrhage or brain injury?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Chest pain, palpitations, heart murmur or any disease or abnormality of your heart, pulse, veins or arteries?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Cancer, tumour, Hodgkin’s disease, lymphoma or leukaemia?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Diabetes or sugar in the urine?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any condition of the nervous system such as epilepsy, fits or blackouts, multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, dementia, cerebral palsy or paralysis?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Mental illness that has required referral to a hospital, community mental health team or psychiatrist, or have you ever attempted self-harm, suicide or had suicidal thoughts?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any disorder of the eyes (including blurred or double vision) or the ears (including impaired hearing)? You can ignore sight problems corrected by glasses or contact lenses

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Raised blood pressure?

No Yes

When was the last time your blood pressure taken?

Please input your reading if known

Please provide any further information

Raised cholesterol?

No Yes

When was the last time your Cholesterol was checked?

Please input your reading if known

Please provide any further information

A lump, growth or cyst of any kind, or any mole or freckle that has bled, become painful, changed colour or increased in size?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Numbness, tingling, tremor, temporary loss of muscle power, or loss of balance or co-ordination?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Asthma, bronchitis, or any other condition affecting your lungs or breathing? You don’t need to tell us about: • common colds or flu, or • one-off chest infections that you’ve fully recovered from

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Anxiety, depression, stress, fatigue or any form of nervous or mental disorder, including eating disorders or work-related stress? If you’ve already told us about your anxiety, depression or mental illness in response to a previous question, there’s no need to tell us about this again here.

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Anaemia or any blood or thyroid disorder?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any disorder of the digestive system, liver, stomach, pancreas or bowel, including gastric or duodenal ulcer, hepatitis, colitis or Crohn’s disease?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any disorder of the kidney, bladder, prostate or genito-urinary system, including blood or protein in the urine?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any arthritis, gout, joint or muscle problems, including the knee(s), shoulder(s), neck, back or spine?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

This question is for both males and females Any breast disorders, for example lumps, cysts, nipple discharge or inverted nipple, or an abnormal mammogram?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

Any more conditions under this category?

No Yes

Please provide details of your condition

When was this first diagnosed?

When was your last symptom?

This question is for females only An abnormal cervical smear or other gynaecological disorder from which you haven’t fully recovered and/or been discharged from follow-up?

No Yes

Please provide details of your condition

Are you awaiting the results of any investigations or are you aware of any symptoms or complaints that you haven’t consulted a doctor or received treatment for? If you’ve already told us about your investigations, symptoms or complaint in response to a previous question, there’s no need to tell us about this again here.

No Yes

Please provide details

Do you have any other information to give us about any medical investigation, test or consultation, advice, counselling, operation, medication or treatment that you’ve had or been advised to have or are currently having, but haven’t already told us about?

No Yes

Please provide details

Please provide details:

You can trust ME for protection advice

Our professional advisers will review your current circumstances including you and your families medical history, your financial situation and your financial goals to make sure we find the right insurance policies for you.

Protection made easy!

At ME we use the latest software which enables us to find you the best deal whilst also helping us to work with you securely and efficiently. Our clients can choose to complete all of the initial information we require in their own time on their mobile, tablet or PC so our advisers can get on with helping you find the solution you need

Specialist protection options for all

Our protection specialists can also help with more complex protection requirements such as business / shareholder protection, group protection policies and key person protection. If you have a business you want to protect, contact ME today.

YOUR HOME MAY BE REPOSSESSED IF YOU DO NOT KEEP UP REPAYMENTS ON YOUR MORTGAGE

Some helpful tips, guides and information to help you on your financial journey

We want to build a long and lasting relationship with you for many years to come and won’t just leave you to it once your transaction has been approved. We are available to hold your hand through the whole process and beyond. As such, we aim to make your life as easy as possible by updating you with regular information and guides.

IS NOW THE RIGHT TIME TO REVIEW YOUR MORTGAGE?

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OUR GUIDE TO CREDIT SCORING

Contrary to popular belief, there are 3 main credit reference agencies, these are Experian, Equifax and Transunion. There are a number of different providers such as Credit Karma and ClearScore which offer you a free report, but.....

OUR TOP 5 WAYS TO REDUCE YOUR OUTGOINGS

We are in extremely uncertain time’s right now, At ME we speak to a lot of clients about their finances and have put together our Top 5 easy wins to reduce your monthly outgoings, all can be done from the comfort of your home. We hope you find this useful! 1. Check your Utility Providers […]

The Top 5 Reasons You Need a Broker

Finding the right mortgage is more complicated than ever. We help lots of clients who have been to their bank or building society, confident they will be accepted for a mortgage but then are refused with no real explanation provided, leaving them disappointed and confused. Your mortgage broker should take the time to understand your […]

Protection

Why do I need it? What is it? It won’t happen to me? The types of protection we are looking at are insurance policies that protect you, your family and your home. There are different policies that can do this by either protecting your life, your income, your partner’s life and/or income. We have written […]

Choosing the right mortgage

A brief guide to help you start on this exciting journey. Looking to buy your first home is a big step. This will probably be the biggest purchase you will ever make. We have put together this first time buyer guide to help along the way as there are certain decisions you will need to make […]

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T 0330 0552506 E enquiries@emailmefs.com

T 0330 0552506 E enquiries@emailmefs.com

PROTECT

Health & Lifestyle Disclosures
...helping ME protect you

In order to find the right cover for you, we need to know a bit of information about your health & lifestyle and work & family history.

Please complete this form as fully and honestly as possible as incorrect information could invalidate and policy claim.

You can trust ME for protection advice

Protection made easy!

Specialist protection options for all

YOUR HOME MAY BE REPOSSESSED IF YOU DO NOT KEEP UP REPAYMENTS ON YOUR MORTGAGE

Some helpful tips, guides and information to help you on your financial journey