Health Disclosure

Step 1 of 8

12%

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(Required)

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.

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

Name(Required)

First Last

Sex(Required)

Date of birth(Required)

DD slash MM slash YYYY

Your Contact Number(Required)

Email(Required)

Dr's Name(Required)

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Doctors Surgery(Required)

Surgery Phone Number

Height(Required)

Weight(Required)

Smoker Status(Required)

Alcohol Consumption(Required)

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

Yes

Do you take part / intend to take part in any of the following hazardous activities?(Required)

Sports Diving

Sailing

Mountaineering

Motor Sports

Caving/Potholing

Aviation

Aviation-related activities (e.g. base jumping, paragliding, skydiving, ballooning etc)

None of the above

Please provide more detail if checked.

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

Yes

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

Yes

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

Yes

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

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)?(Required)

Yes

Occupation(Required)

Occupation Type

Do you work under the following conditions?(Required)

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)

None of the Above

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?(Required)

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

Cancer, tumour, Hodgkin’s disease, lymphoma or leukaemia?(Required)

Yes

Diabetes or sugar in the urine?(Required)

Yes

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?(Required)

Yes

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?(Required)

Yes

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(Required)

Yes

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

Yes

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

Yes

Asthma, bronchitis, or any other condition affecting your lungs or breathing?(Required)

No need to include common colds or flu, or • one-off chest infections that you’ve fully recovered from

Yes

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

Yes

Anaemia or any blood or thyroid disorder?(Required)

Yes

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

Yes

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

Yes

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?(Required)

Yes

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

Yes

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.(Required)

Yes

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.(Required)

Yes

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?(Required)

Yes

To the best of your knowledge, have any of your parents, brothers or sisters, died or been diagnosed with any of the following diseases/disorders before the age of 65 - Select all that apply

Heart attack, angina or stroke

Diabetes

Cancer of the breast, ovaries or bowl or familial bowel polyps

Alzheimer's disease

Parkinson's disease

Polycystic kidney disease

Polyposis of the colon

Motor neurone disease

Multiple sclerosis

Hunington's disease

Muscular dystrophy

Cardiomyopathy

Any other hereditary disorder- please give information below

None of these

Please select the adviser you are working with

Amy Dyble

Health Disclosure

Health Disclosure

Red Barrow Mortgage Solutions Ltd is registered in England and Wales. No. 16012841. Registered Office: 16 Hennals Avenue, Redditch, Worcestershire, B97 5RX.

Red Barrow Mortgage Solutions Ltd is an Appointed Representative of Cornerstone Finance Group Ltd, which is authorised and regulated by the Financial Conduct Authority.

Cornerstone Finance Group Ltd is registered in England & Wales. No. 08458702. Registered Office: Unit E Copse Walk, Pontprennau, Cardiff, Wales, CF23 8RB.

Red Barrow Mortgage Solutions Ltd (No. 1031835) and Cornerstone Finance Group Ltd (No. 767202) are entered on the Financial Services Register at https://register.fca.org.uk/

Red Barrow Mortgage Solutions