Underwriting
If any question is answered "Yes", details must be provided as additional information in the underwriting interview.
Have you ever had symptoms, been diagnosed with, consulted a medical- and/or health- and/or alternative health practitioner, taken
medication or had treatment, been given advice, been hospitalised for, had any tests, investigations or had surgery related to?
Please select all that apply:
1. Your heart or circulation?
Name, telephone number and address of the attending doctor/s or the doctor/s consulted. (Please provide the information for each disclosure).
When did you last visit the doctor for this condition?
2. Your lungs or other breathing problems (excluding colds, influenza)?
Name, telephone number and address of the attending doctor/s or the doctor/s consulted. (Please provide the information for each disclosure).
When did you last visit the doctor for this condition?
3. Your digestive system, including stomach, small bowel, large bowel and liver?
Name, telephone number and address of the attending doctor/s or the doctor/s consulted. (Please provide the information for each disclosure).
When did you last visit the doctor for this condition?
4. Your kidneys, bladder and reproductive organs?
Name, telephone number and address of the attending doctor/s or the doctor/s consulted. (Please provide the information for each disclosure).
When did you last visit the doctor for this condition?
5. Your nervous system, and mental health conditions?
Name, telephone number and address of the attending doctor/s or the doctor/s consulted. (Please provide the information for each disclosure).
When did you last visit the doctor for this condition?
6. Your ears, eyes, nose or throat?
Name, telephone number and address of the attending doctor/s or the doctor/s consulted. (Please provide the information for each disclosure).
When did you last visit the doctor for this condition?
7. Your skin, muscles, bones, joints, limbs and spine?
Name, telephone number and address of the attending doctor/s or the doctor/s consulted. (Please provide the information for each disclosure).
When did you last visit the doctor for this condition?
8. Your glands or blood, including diabetes or raised blood sugar tests?
Name, telephone number and address of the attending doctor/s or the doctor/s consulted. (Please provide the information for each disclosure).
When did you last visit the doctor for this condition?
9. Cancer, growth or tumour of any kind, including moles removed?
Name, telephone number and address of the attending doctor/s or the doctor/s consulted. (Please provide the information for each disclosure).
When did you last visit the doctor for this condition?