Quantock Financial
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Health and lifestyle questionnaire

Speak to an adviser 01823 426046

Three generations of a family walking through the dunes

Client questionnaire

For your life insurance, critical illness and income protection application

Now that you have your mortgage offer and our protection recommendation, the next step is to apply to the insurer. These questions cover the health and lifestyle details insurers ask about, so we can complete your application accurately and avoid delays.

How to fill it in

  • Fill in the form below and press Submit when you have finished.
  • Applying with someone else? Choose Joint application and answer for both of you.
  • It takes around 10 minutes.

When you have finished

  • Press Submit and your answers will be sent securely to our office.
  • Not sure about something? Leave it blank and we will go through it together.

Honest answers protect your cover

Please answer every question fully and honestly, even if something seems minor or happened a long time ago. If information given to an insurer is missing or incorrect, it could reduce a claim or mean a claim is not paid. If in doubt, tell us.

Is this a single or joint application?

Fields marked * are required. Everything else is optional: if you’re not sure, leave it blank and we’ll go through it together.

01 Lifestyle

Full name *

Height

Weight

Waist or dress size

How much alcohol do you drink a week?

In units. A pint of beer or a glass of wine is about 2 units

In the last 5 years, have you smoked or used any tobacco, nicotine products, vapes or e-cigarettes?

If yes, when did you last smoke or use them?

In the last 5 years, have you used any recreational drugs?

Do you have any extreme hobbies or take part in any extreme sports?

e.g. diving, climbing, motor sport, flying, combat sports

Do you plan to travel outside the UK, Europe, USA, Canada, Australia or New Zealand in the next 12 months?

How many days have you been off sick in the last year?

02 Your health

GP surgery name and address

Are you waiting for any medical investigations, tests, referrals or results?

In the last 5 years, have you visited a doctor about anything that is still ongoing?

In the last 5 years, have you been referred to a specialist?

Have you ever had any mental health condition, including stress or anxiety?

Do you have any other current medical conditions?

Are you currently taking any prescribed medication?

Have you ever had any of the following?

Tick the box under your column for anything that applies to you.

Asthma
Back pain
Abnormal cervical smear result
Diabetes
Epilepsy
Headaches or migraines
High blood pressure
High cholesterol
Irritable bowel syndrome
Lumps, bumps or growths
Numbness or tingling
Thyroid disorder

If you answered yes to any health question

Please include when it started, any treatment or medication and whether it is ongoing.

03 Family history

Have any of your parents, brothers or sisters had a serious illness, such as heart attack, stroke, cancer, diabetes or multiple sclerosis?

04 Anything else

05 Declaration

I confirm that the information in this questionnaire is true and complete to the best of my knowledge. I understand that Quantock Financial will use it to complete my protection application, and that the insurer’s questions will be checked with me before anything is submitted. I understand that if information given to an insurer is incorrect or incomplete, a claim could be reduced or refused.

The date is added automatically when you press Submit.

Please read our privacy statement before making an enquiry.

What happens next We will use your answers to complete your application and go through it with you before it is sent to the insurer.

Speak to an adviser 01823 426046 · [email protected]

Your information is kept securely and used only to arrange your protection, in line with our privacy notice. We only share your health details with insurers when you agree to go ahead with an application.