Becca - The Protection Parent

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1You

2Employment

3Financial

4Health

5Optional

6Confirmation

Personal Details

Full Name*

Title First Last

Email address*

Contact number*

Interested In?*

Select Option(s)

Cancer Insurance

Critical Illness Cover

Life Insurance

ChildShield

Income Protection

Zurich Accelerate

Children’s Critical Illness Cover

Will Writing

Pregnancy Cover

Fracture Cover

Unsure

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What are you interested in getting quotes for?*

Life insurance

Critical Illness Cover

Income Protection

Mortgage Protection

Global Cancer Treatment

Children's Critical Illness

Unsure

Date of birth*

Do you smoke, vape or use any nicotine based products?*

Yes

Ex-Smoker

If yes how many per day? If you vape, is this nicotine or non-nicotine based?*

When did you stop ?*

What is your nationality?*

British

Northern Irish

EU National

Other

What is your gender?*

Female

Male

What is your marital status?*

Single

Co-habiting

Married

Divorced

Widowed

Is the insurance just for you?*

If it is for yourself and a partner please select 'No'.

Yes

What is your current residency status?*

Owner

Privately renting

Renting from council

Living with parents or partner

Other

Current address*

Street Address Address Line 2 City County Post Code Country

What date did you move into your current property?*

If you have lived at this address for less than 3 years, please provide your previous addresses over the last 3 years below

Do you have any children?*

Yes

Please provide details of each child

Full Name

D.O.B

Gender

How did you hear about us?

Employment Details

What is your employment status?*

Employed

Self employed (Sole trader)

Self employed (own more than 20% of a limited company)

Contractor

Student

Other (Please specify)

Other employment status*

Is it a permanent contract?

Yes

Employer Name

What is your job title?

What is your annual salary?

Including bonus, commission, overtime, etc

Do you work at a height?

Yes

Do you work offshore?

Yes

What waters?

Do you receive sick pay from work?

Yes

How long for?

How long could you survive without any pay?

Under 1 month

1-2 months

3-6 months

12 months +

Financial Details

Do you have a mortgage?*

If you are in the process of applying for your mortgage please tick 'yes'

Yes

What is your outstanding mortgage balance?

If you are applying for a mortgage please state the new mortgage amount.

Do you know how many years you have left on the mortgage?*

Yes

I don't know

How many years do you have remaining on your mortgage?

What is the name of your trustee?

Your chosen trustee is a person you trust with your money when you pass away.

What is your trustee's DOB?

Applicant 1 Details

What is your height?*

Feet & Inches

What is your weight?*

Stone & lbs

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What is your height (inches)*

Inches

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What is your weight? (pounds)*

Pounds

What is your dress size or waist size?*

e.g. size 12/34 inch waist

On average how many alcoholic drinks do you have in a typical week?*

Have you ever been advised to reduce your drinking on medical grounds?*

Yes

Have you ever taken non-prescription drugs?*

eg. heroin, ecstasy, cocaine

Yes

Have any of your parents, brothers or sisters died before the age of 65?*

Yes

Please provide details

Relative

Condition

Age of diagnosis

Age of death

Have any of your parents, brothers or sisters suffered from any of the following before the age of 65?*

Cancer

Diabetes

Heart Attack

Strokes

Angina

Polycystic kidney disease

Heart disease

Multiple Sclerosis

Parkinson's

Huntington's disease

Alzheimer's

Muscular Dystrophy

Motor neurone

Cardiomyopathy

Ovaries/bowel/familial bowel polyps

Other hereditary disorders

None

Please provide details

Relative

Condition

Age of diagnosis

Age of death

Have you been tested for anything that runs in your family?*

Yes

Please provide details of what you were tested for and when you were tested

Have you had or currently have any of the following?*

Cancer

Leukaemia

Hodgkin’s disease

Lymphoma

Brain/spinal tumour

Multiple sclerosis

Parkinson’s disease

Paralysis

Epilepsy

Alzheimers/dementia

Cerebral palsy

Stroke/mini stroke

Brain damage

Heart disorder/attack/angina

Diabetes

Disorder of the CNS

Crohns disease/Ulcerative colitis

Major organ transplant

HIV

Weight loss treatment or Mounjaro

None

Please give details of the condition

Date of diagnosis, past/current treatment, current status, medication, any time off work etc.

Have you had/have any of the following?*

Lump/growth/mole/freckle that has been investigated

Chest pain/blood circulation concerns

Raised/lowered blood pressure

Raised cholesterol

Asthma/bronchitis

Gout

Numbness/loss of feeling of limbs

Migraines/blackouts/seizures/fainting

Eye/ear disorder

Arthritis/osteoporosis

Sciatica/whiplash/trapped nerves

Thyroid disorder

Joint/bone/muscle disorder

Disorder of the digestive system (Including IBS)

Blood disorder (including anaemia/haemophilia)

Skin conditions/diseases

STDs

Disorder of the kidney/bladder/liver/panaceas

Gynaecological (abnormal smear tests)

Prostate concerns

Mental health issues (including anxiety, depression, stress, post natal depression etc)

Broken bones

Covid

None

Please give details of the condition

Date of diagnosis, past/current treatment, current status, medication, any time off work etc.

In the last 5 years, have you attended any doctor, hospital, or clinic for any medical advice, treatment, investigations or tests?*

Yes

Please confirm reason, last known symptoms/concern, treatment given, current treatment, current status, amount of time off work*

Have you been signed off by a doctor with a sick note in the last five years?

If yes, please state how long and why?

Are you waiting for any treatment, appointments, referrals or under any form of medical supervision?*

Yes

Please give details

Have you ever undergone a surgical procedure outside of the EU or been a recipient of blood products outside of the EU?

Yes

Please state the country and the surgery

Do you have any other medical condition that you have not previously mentioned ?*

Yes

Please state your medical conditions.*

Doctor's Surgery Name

Doctor's Email

If possible, please provide your Doctor's Email Address.

Doctor's Telephone Number

If possible, please provide your Doctor's Telephone Number.

Doctor's Surgery Address

Street Address Address Line 2 City County Post Code Country

Are you happy for the insurer to contact your doctors if needed?

This includes requesting your medical records.

Yes

Do you have a will?*

If so, please make sure it is updated with any new policies. If not, we can help you get one set up once your policies are active.

Yes

Applicant 2 Details

Full Name*

Title First Middle Last

Date of birth*

Do you smoke, vape or use any nicotine based products?*

Yes

Ex-Smoker

If yes how many per day? If you vape, is this nicotine or non-nicotine based?*

When did you stop ?*

What is your nationality?*

British

Northern Irish

EU National

Other

What is your gender?*

Female

Male

Email address*

Contact number*

What is your marital status?*

Single

Co-habiting

Married

Divorced

Widowed

What is your current residency status?*

Owner

Privately renting

Renting from council

Living with parents or partner

Other

Is your address the same as Applicant 1?*

Yes

Address

Street Address Address Line 2 City County Postcode Country

Employment Details (Applicant 2)

What is your employment status?*

Employed

Self employed (Sole trader)

Self employed (own more than 20% of a limited company)

Contractor

Student

Other (Please specify)

Other employment status*

Is it a permanent contract?

Yes

Employer name

What is your job title?

What is your annual salary?

Including bonus, commission, overtime, etc

Do you work at a height?

Yes

Do you work offshore?

Yes

What waters?

Do you receive sick pay from work?

Yes

How long for?

How long could you survive without any pay?

Under 1 month

1-2 months

3-6 months

12 months +

What is your height?*

Feet & Inches

What is your weight?*

Stone & lbs

This field is hidden when viewing the form

What is your height? (Inches)

Inches

This field is hidden when viewing the form

What is your weight? (Pounds)

Pounds

What is your dress size or waist size?*

e.g. size 12/34 inch waist

On average how many alcoholic drinks do you have in a typical week?*

Have you ever been advised to reduce your drinking on medical grounds?*

Yes

Have you ever taken non-prescription drugs?*

eg. heroin, ecstasy, cocaine

Yes

Have any of your parents, brothers or sisters died before the age of 65?*

Yes

Please provide details

Relative

Condition

Age of diagnosis

Age of death

Have any of your parents, brothers or sisters suffered from any of the following before the age of 65?

Cancer

Diabetes

Heart Attack

Strokes

Angina

Polycystic kidney disease

Heart disease

Multiple Sclerosis

Parkinson's

Huntington's disease

Alzheimer's

Muscular Dystrophy

Motor neurone

Cardiomyopathy

Ovaries/bowel/familial bowel polyps

Other hereditary disorders

None

Please provide details

Relative

Condition

Age of diagnosis

Age of death

Have you been tested for anything that runs in your family?*

Yes

Please provide details of what you were tested for and when you were tested

Have you had or currently have any of the following?

Cancer

Leukaemia

Hodgkin’s disease

Lymphoma

Brain/spinal tumour

Multiple sclerosis

Parkinson’s disease

Paralysis

Epilepsy

Alzheimers/dementia

Cerebral palsy

Stroke/mini stroke

Brain damage

Heart disorder/attack/angina

Diabetes

Disorder of the CNS

Crohns disease/Ulcerative colitis

Major organ transplant

HIV

Weight loss treatment or Mounjaro

None

Please give details of the condition

Date of diagnosis, past/current treatment, current status, medication, any time off work etc.

Have you had/have any of the following?

Lump/growth/mole/freckle that has been investigated

Chest pain/blood circulation concerns

Raised/lowered blood pressure

Raised cholesterol

Asthma/bronchitis

Gout

Numbness/loss of feeling of limbs

Migraines/blackouts/seizures/fainting

Eye/ear disorder

Arthritis/osteoporosis

Sciatica/whiplash/trapped nerves

Thyroid disorder

Joint/bone/muscle disorder

Disorder of the digestive system (Including IBS)

Blood disorder (including anaemia/haemophilia)

Skin conditions/diseases

STDs

Disorder of the kidney/bladder/liver/panaceas

Gynaecological (abnormal smear tests)

Prostate concerns

Mental health issues (including anxiety, depression, stress, post natal depression etc)

Broken bones

Covid

Please give details of the condition

Date of diagnosis, past/current treatment, current status, medication, any time off work etc.

In the last 5 years, have you attended any doctor, hospital, or clinic for any medical advice, treatment, investigations or tests?*

Yes

Please confirm reason, last known symptoms/concern, treatment given, current treatment, current status, amount of time off work*

Have you been signed off by a doctor with a sick note in the last five years?

If yes, please state how long and why?

Are you waiting for any treatment, appointments, referrals or under any form of medical supervision?*

Yes

Please give details

Have you ever undergone a surgical procedure outside of the EU or been a recipient of blood products outside of the EU?

Yes

Please state the country and the surgery

If there is any other medical condition that you have not previously mentioned, please state below

Please note any undisclosed conditions will void a claim

Doctor's Surgery Name

Only if different to partners

Doctor's Email

If possible, please provide your Doctor's Email Address.

Doctor's Telephone Number

If possible, please provide your Doctor's Telephone Number.

Doctor's Surgery Address

Street Address Address Line 2 City County Post Code Country

Are you happy for the insurer to contact your doctors if needed?

This includes requesting your medical records. Please let me know if you would like a copy of this before it is sent to the insurer

Yes

Do you have a will?*

If so, please make sure it is updated with any new policies. If not, we can help you get one set up once your policies are active.

Yes

This field is hidden when viewing the form

What are you interested in getting quotes for?*

Life insurance

Critical Illness Cover

Income Protection

Mortgage Protection

Global Cancer Treatment

Children's Critical Illness

Unsure

By submitting this form, I confirm that I have answered all questions open and honestly to the best of my ability.

Consent*

I agree to the privacy policy and that by submitting this form, I confirm that I have answered all questions open and honestly to the best of my ability.

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Applicant 1 Details

Applicant 2 Details

Employment Details (Applicant 2)

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