Life Insurance for non-UK Residents – Proposal Form

Please ensure that all questions are fully answered to the best of your knowledge and belief. All material facts must be disclosed as failure to do so may nullify any Policy or Certificate issued (a material fact is one likely to influence the assessment and acceptance of the Proposal by the Underwriters). If you are in any doubt as to whether a fact is material it should be disclosed. If you consider that the answer to any questions in the Proposal Form requires expert knowledge which you do not have, please indicate this in your answer.
Please complete in black ink, using block capitals.
Details of applicant:
Name of all entities to be insured:
Date of Birth: / Nationality: / Marital Status:
Address of the Applicant:
Telephone Number (Home): / Telephone Number (Work):
Occupation (please give full details including exact duties):
Details of cover required:
Sum to be Insured: / Currency:
Period of Cover: / Commencement Date:
Please state the reason why this Life Insurance is required:
Is the Sum to be Insured: / Level / Decreasing / Increasing / (please tick)
If the Sum to be Insured is decreasing/increasing, please state how it decreases/increases:
Personal Details:
Name and address of your usual doctor: / Telephone Number:
Name and address of your previous doctor:
(if with present doctor less than 12 months) / Telephone Number:
When and for what reason did you last seek medical advice?
Are you currently receiving medication or treatment of any kind (prescription and/or non-prescription drugs, acupuncture, homeopathy, etc) or are you on any special diet? Please give full details.
Height:
(without shoes) / Weight:
(in indoor clothes) / Is weight static, increasing or decreasing:
Have you smoked any form of tobacco within the last 12 months? If so, please state type and quantity.
How much and what type of alcohol do you drink in a week? If you previously drank alcohol but now abstain, please state the type and quantity consumed, together with the date and reason for stopping. If you are a lifelong non-drinker, please state so.
NO / YES / If yes, full details
Have you ever been requested by a doctor to reduce or stop your consumption alcohol or tobacco?
Do you, or do you intend to fly other than as a fare-paying passenger scheduled airline or participate in any aerial sports, pastimes or pursuits, such as hand-gliding, parachuting, ballooning or micro-lighting?
Do you travel abroad other than for holidays?
Do you, or do you intend to engage in any hazardous sports, pastimes or pursuits such as rugby, equestrian sports, mountaineering, caving, diving, motor racing or winter sports?
Have you effected, or have any proposals been made to insurers for life, sickness, health, accident or disability insurance on your life within the last two years, or are you making a concurrent application with any other Office(s)? If so, when and to which Office(s)?
Has any proposal for life, sickness, health, accident or disability insurance on your life, or request for reinstatement thereof, ever been declined, postponed, accepted on special terms or modified in any way? If so, when and by which Office(s)?
Medical History:
Please answer the following questions carefully, if you answer YES please supply full details, the treatment given and the doctor consulted, including the appropriate dates (if necessary please continue in the space provided on page 5).
NO / YES / If yes, full details
1. Has either your mother, father any brothers, sisters died? (please state age and cause of death where applicable)
2. Do you have any physical defect or infirmity or is yoursight or hearing defective?
3. Have you ever suffered from: -
(a) depression, nervous breakdown, fainting episode, epilepsy, fits, any nervous or psychological condition or paralysis of any kind?
(b) high or low blood pressure, a heart condition, chest pains, stroke, rheumatic or any other circulatory disorder?
(c) a slipped disc, any other spinal disorder, or any rheumatic or arthritic condition?
(d) asthma, bronchitis, pleurisy, tuberculosis or any disease of the lungs?
(e) gastric or duodenal ulcer, hernia, persistent indigestion, colitis, bowel or any other intestinal disorder?
(f) diabetes, gout, kidney, liver, prostate, thyroid or bladder problem?
(g) tumors, cysts or growths of any kind?
(h) any dietary problem, illness or injury not mentioned above which required treatment?
4. Have you ever undergone a surgical operation, x-rays or special investigations, or are you expecting to do so in the future?
Questions 5, 6, 7 & 8 which follows may, if you prefer, be answered separately and sent in a sealed envelope for the attention of Marc Frost, Beazley Group plc, Plantation Place South, 60 Great Tower Street, London EC3R5AD, ENGLAND.
NO / YES / If yes, full detail
5. Have you ever tested positive for HIV or are you awaiting the result of such a test?
If you have answered “yes”, please specify:
Tested positive for HIV
Awaiting an HIV test result
Note: if the result is negative, the fact of having an HIV test will not, or itself, have any effect on your acceptance terms for insurance.
6. Have you ever injected non-prescription drugs?
7. Within the last 5 years, have you been exposed to the risk of HIV infection?
8. Within the last 5 years, have you tested positive or been treated for any disease, which was transmitted sexually?
Declaration:
Please read the Notice of Statutory Rights under the Access to Medical Reports Act 1988 on page 8 before completing this Declaration.
If this form has been filled in by someone else on your behalf, you should read the answers carefully before signing the following Declaration.
Please remember that any omission or misstatement of a material fact in this form could affect the payment of benefits under any Policy or Certificate issued. A material fact is one likely to influence the assessment and acceptance of the Proposal by the Underwriters. If you are in any doubt as to whether a fact is material it should be disclosed.
I, the Life to be Insured and, if different, the Proposer, declare that the foregoing statements are true and complete answers to the best of my/our knowledge and belief. I/We undertake to inform the Underwriters of any changes to these statements which occur before the contract completes and I/We understand that failure to do so may affect the validity of the contract.
I, the Life to be Insured consent to Underwriters seeking medical information from any doctor who at any time has attended me concerning anything which affects my physical or mental health or seeking information from any insurance office to which an Application/Proposal has been made for insurance on my life and I authorize the giving of such information.
I, the Life to be Insured agree that this Proposal shall form the basis of the Insurance and will be incorporated in the Policy or Certificate of Insurance.
I have read my Statutory Rights under the Access to Medical Reports Act 1988 as explained on page 8 and I do not* wish to see a report before it is sent to Underwriters. I agree that a copy of this consent shall have the validity of the original.
Signature of the Life to be Insured: / Dated:
Signature of the Person Proposing the Insurance: / Dated:
Name and Address of Proposer:
Insurable Interest/Relationship of Proposer:
*Only delete the word not if you do wish to see your medical report.
Additional Information (please continue answers to questions on previous pages here, if necessary)

Life Insurance Proposal FormPage 1 of 5