Protector Plans Application Form

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Which plan suits your needs best? *

Emergency+
Standard
Plus
Premium
Executive

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How much excess would you like to pay? *

$0
$250
$1,000
$2,000

How much excess would you like to pay? *

$250
$1,000

This is fixed amount you must pay out of pocket each policy year for covered medical services before HCI Group Global starts reimbursing costs.

How much excess would you like to pay? *

$0
$250
$1,000

This is a fixed amount you must pay out of pocket each policy year for covered medical services before HCI Group Global starts reimbursing costs.

How much would you like to set your co-pay as? *

This is a fixed amount that you will pay at the time of receiving a covered service or medication.

What currency would you like your policy to be in? *

USD (default)
I will contact HCI to request my policy in GBP or Euros. Send email

When would you like the cover to start? *

Full Medical Underwriting

This application form is for Full Medical Underwriting.

We take your full medical history and, depending on your answers, we can exclude certain conditions meaning you won’t be able to claim on them but this will give you a 10% discount for life. You can always ask us to review your exclusions if your health changes.

Choose your underwriting *

Full Medical Underwriting
Moratorium
Other - please contact us. Send email

Your health

1. Does anyone on this plan have any physical defect or infirmity? *

2. Has anyone suffered from any recurring illness or injury or taken prescribed drugs regularly? *

3. Has anyone had a surgical operation in the last five years for cancer or heart disease or is it likely that they’ll have one in the future? *

4. Has anyone seen a doctor in the last two years or will need to in the near future? *

5. Does anyone play any dangerous sports or activities? *

Full Medical Underwriting questions

Do you smoke or use tobacco products? *

Has anyone been advised, counselled, tested, diagnosed, treated, hospitalised or recommended for treatment in the last 10 years for the following:

6. Seizures or seizure disorder, paralysis, multiple sclerosis or any disorder of the central nervous system *

Neurology medical questionnaire

Which policyholder(s) have experienced seizures or seizure disorder, paralysis, multiple sclerosis or any disorder of the central nervous system?

6.1 Symptoms / diagnosis

6.2 Date of onset

6.3 Date of last episode

6.4 Are you currently experiencing any symptoms?

6.5 Are you performing activities of daily living (bathing, dressing, eating etc) with:

Little or no difficulty
Moderate difficulty
Extreme difficulty

6.6 What degree of muscle strength do you have?

Little or no difficulty
Moderate difficulty
Complete loss

6.7 What degree of bladder / bowel function do you have?

Little or no difficulty
Partial loss
Complete loss

If you have difficulties, please give details

6.8 Have you ever had problems with:

Vision
Swallowing
Breathing
Fatigue
Seizures
Numbness, losss of feeling or tingling
Weakness, loss of muscle strength
Memory loss or impaired mental ability
Other

If you have had problems, please give details

6.9 Are you taking any medication?

Details of medication 1 (Type, dose, frequency)

Details of medication 2 (Type, dose, frequency)

Details of medication 3 (Type, dose, frequency)

Are you still taking it?

Date medication was stopped

Please provide details of any further medication if applicable

6.10 Have you had a CT Scan

Date of latest CT scan

Results of latest CT scan

6.11 Have you had a MRI scan?

Date of latest MRI scan

Results of latest MRI scan

6.12 Have you had any other tests other than a CT scan / MRI scan?

Please provide the type of test(s), the date(s) and the result(s).

6.13 Have you ever been hospitalised for a neurology condition?

Please give dates and details

6.14 Are you currently under any other treatment not yet mentioned?

Please give details

7. Mental retardation, any mental, behavioural, emotional or eating disorder, anxiety, depression, neurosis or psychosis, psychotherapy, psychological, marital or any type of counselling or therapy *

Mental Health Medical Questionnaire

Which policyholder(s) have experienced mental retardation, any mental, behavioural, emotional or eating disorder, anxiety, depression, neurosis or psychosis, psychotherapy, psychological, marital or any type of counselling or therapy?

7.1 On what date did you first consult a physician?

7.2 What diagnosis was made?

7.3 How frequent are the symptoms? (state number per month /year)

7.4 What was the date of the most recent episode of symptoms?

7.5 Are you taking any medication?

List medication name(s), dosage and frequency

7.6 Who has prescribed this medication?

7.7 Give details of any limitations in daily activities you currently have as a result of your coondition

7.8 Has there been any time lost from work due to this condition?

Please give dates and details

7.9 Has there been any hospital treatment or referral to a Psychiatrist?

Please give dates and details

7.10 Are you or have you ever received psychotherapy / counselling?

Please provide details

7.11 Was / is this condition triggered by any particular factor?

Please provide details

7.12 Have you ever received electro-convulsive therapy?

Please provide details

7.13 Have you ever tried to take your own life?

Please say when and provide details

7.14 Are you fully recovered from this condition?

Please confirm date of discharge from follow up

8. High blood pressure, heart attack, stroke, chest pain or palpitations, murmur, varicose veins, blood clot, anaemia or any other blood, heart or circulatory disorder or condition *

Cardiology questionnaire

8.1 Has anyone to be covered on the policy ever had symptoms or been diagnosed with any type of heart disorder or cardiovascular disease?

Policyholder

PH | Angina

PH | Heart Attack

PH | Cardiomyopathy (CM)

PH | Coronary Artery Disease

PH | Heart Infections

PH | Arrhythmia / Abnormal Pulse

PH | Abnormal ECG

PH | Ventricular Fibrillation / Flutter

PH | Valve Disease / Disorder

PH | Peripheral Artery Disease

PH | High Blood Pressure

PH | Heart Murmur

PH | Congenital Heart Conditions

PH | Inherited Heart Conditions

PH | Stroke / TIA

Date of onset

Date | Angina

Date | Heart Attack

Date | CM

Date | CAD

Date | Heart infections

Date | A/A Pulse

Date | Abnormal ECG

Date | VF/F

Date | Valve disease

Date | PAD

Date | HBP

Date | Heart Murmur

Date | CHC

Date | IHC

Date | Stroke / TIA

Treatment

Treatment | Angina

Treatment | Heart Attack

Treatment | CM

Treatment | CAD

Treatment | Heart infections

Treatment | A/A Pulse

Treatment | Abnormal ECG

Treatment | VF/F

Treatment | Valve disease

Treatment | PAD

Treatment | HBP

Treatment | Heart Murmur

Treatment | CHC

Treatment | IHC

Treatment | Stroke / TIA

Current status

Status | Angina

Status | Heart Attack

Status | CM

Status | CAD

Status | Heart infections

Status | A/A Pulse

Status | Abnormal ECG

Status | VF/F

Status | Valve disease

Status | PAD

Status | HBP

Status | Heart Murmur

Status | CHC

Status | IHC

Status | Stroke / TIA

8.2 Have any of the following tests been completed?

Have any policyholders had a Thalium Stress ECG test?

Date | Thalium Stress ECG

Results | Thalium Stress ECG

Have any policyholders had a Stress Echocardiogram?

Date | Stress ECG

Results | Stress ECG

Have any policyholders had a Coronary Angiography?

Date | CA

Results | CA

Have any policyholders had an Echocardiogram?

Date | ECG

Results | ECG

Have any policyholders had a Chest X-Ray?

Date | Chest X-Ray

Results | Chest X-Ray

Other tests not listed here

Please provide details of the test(s), the date(s) and the result(s).

8.3 Do all policyholders exercise on a regular basis?

8.4 Have any policyholders ever been diagnosed with any of the following?

Abnormal lipid levels

Details

Elevated homocysteine

Details

Diabetes

Details

High blood pressure

Details

Peripheral Vascular Disease

Details

Irregular heartbeat

Details

Cancer

Details

Overweight

Details

Elevated cholesterol

Details

Date of last cholesterol test

HDL / total cholesterol ratio

Cerebrovascular or carotid disease

Details

8.5 Have any policyholders had bypass or stenting surgery?

Number of vessels by-passed

How badly were the vessels occluded?

Please give a percentage.

Has a follow up stress exercise ECG been completed since the procedure?

No
Yes - normal result
Yes - abnormal result

Date of test

Has there been any chest discomfort since the procedure?

Please provide details

Is any policyholder taking medication?

Name of medication 1

Name of medication 2

Name of medication 3

Name of medication 4

Name of medication 5

Name of medication 6

Dosage | med 1

Dosage | med 2

Dosage | med 3

Dosage | med 4

Dosage | med 5

Dosage | med 6

Symptoms / Condition | med 1

Symptoms / Condition | med 2

Symptoms / Condition | med 3

Symptoms / Condition | med 4

Symptoms / Condition | med 5

Symptoms / Condition | med 6

9. Asthma, emphysema, bronchitis, sinusitis, pneumonia, allergies, apnea or any breathing difficulty, lung or respiratory disease, disorder or condition *

Respiratory medical questionnaire

How many policyholders have respiratory medical issues?

9.1 What is the diagnosis?

9.1 Additional policyholder: Name and diagnosis?

9.2 When was the condition first diagnosed?

9.2 Additional policyholder: When was the condition first diagnosed?

9.3 How frequent are the symptoms? (state number per month/year)

9.3 Additional policyholder: How frequent are the symptoms? (state number per month/year)

9.4 How disabling are the attacks? To what extent are your normal activities limited by an attack?

9.4 Additional policyholder: How disabling are the attacks? To what extent are your normal activities limited by an attack?

9.5 When was the most recent episode of symptoms?

9.5 Additional policyholder: When was the most recent episode of symptoms?

9.6 Are the symptoms seasonal or throughout the year?

9.6 Additional policyholder: Are the symptoms seasonal or throughout the year?

9.7 Has there ever been hospitalisation for this condition?

9.7 Additional policyholder: Has there ever been hospitalisation for this condition?

Please give dates and details

9.8 Is any medication being taken? (including inhalants?)

9.8 Additional policyholder: Is any medication being taken? (including inhalants?)

Please list names, dosage and frequency

Additional policyholder: Please list names, dosage and frequency

9.9 Are the symptoms

Mild
Moderate
Severe
Productive of sputum
Productive of blood

9.9 Additional policyholder: Are the symptoms

Mild
Moderate
Severe
Productive of sputum
Productive of blood

9.10 Have steroids (eg prednisolone) ever been prescribed?

9.10 Additional policyholder: Have steroids (eg prednisolone) ever been prescribed?

Please provide details

Additional policyholder: Please provide details

9.11 What were the dates and results of your last pulmonary function test, chest xray or allergy test?

9.11 Additional policyholder: What were the dates and results of your last pulmonary function test, chest x-ray or allergy test?

9.12 How often are you being followed up and by whom?

9.12 Additional policyholder: How often are you being followed up and by whom?

9.13 Has there been any time lost from work due to this condition?

9.13 Additional policyholder: Has there been any time lost from work due to this condition?

Please give dates and details

9.14 Please give details of your smoking habits before and after diagnosis

9.14 Additional policyholder: Please give details of your smoking habits before and after diagnosis

9.15 If any further policyholders have respiratory medical issues please provide full details here

10. Colitis, chronic diarrhoea or intestinal problems, hernia, ulcer of the stomach or duodenum, haemorrhoids or rectal disorder, hepatitis or liver disorder, gallbladder, pancreas, oesophagus or any other digestive disorder or condition *

Gastroenterology medical questionnaire

How many policyholders have gastroenterology medical issues?

10.1 Diagnosis

eg dudenal/gastric ulcer, Crohn's, ulcerative colitis

10.1 Additional policyholder: Name and diagnosis

eg dudenal/gastric ulcer, Crohn's, ulcerative colitis

10.2 Date of diagnosis

10.2 Additional policyholder: Date of diagnosis

10.3 How frequent are the symptoms?

State the average number per month / per year

10.3 Additional policyholder: How frequent are the symptoms?

State the average number per month / per year

10.4 When was the most recent episode of symptoms?

10.4 Additional policyholder: When was the most recent episode of symptoms?

10.5 Have you ever had signs of bleeding or any other symptoms from the problem? (eg anaemia, blood in stool or vomit etc)

10.5 Additional policyholder: Has there been signs of bleeding or any other symptoms from the problem? (eg anaemia, blood in stool or vomit etc)

Please provide dates and details

10.6 Have you had any investigations or tests or do you have any planned?

10.6 Additional policyholder: Has there been any investigations or tests or are any planned?

Please give details, dates and the results

10.7 Have you ever had or are you awaiting any surgery for the problem?

10.7 Additional policyholder: Has there ever been are you awaiting any surgery for the problem?

Please provide dates and details of the surgical procedure(s)

10.8 Have you taken medications in the past?

10.8 Additional policyholder: Have medications been taken in the past?

Please list the name(s), dosage and frequency of medication taken

10.9 Are you taking any medications now?

10.9 Additional policyholder: Are any medications being taken now?

Please list the name(s), dosage and frequency of medication taken

10.10 Do you require other types of treatment such as dietary modifications?

10.10 Additional policyholder: Are other types of treatment such as dietary modifications required?

Please give dates and details

10.11 Has there been any hospitalisation or time lost from work due to this condition?

10.11 Additional policyholder: Has there been any hospitalisation or time lost from work due to this condition?

Please give dates and details

10.12 Are you fully recovered from this condition?

10.12 Additional policyholder: Are they fully recovered from this condition?

Please confirm date of discharge from follow up

Additional policyholder: Please confirm date of discharge from follow up

10.13 If any further policyholders have gastroenterology issues please provide full details here

11. Cancer, tumour, growth, cyst, enlarged lump nodes, psoriasis, keratosis, lesions of the skin or mouth, or any other skin disorder *

Cancer Medical Questionnaire

How many policyholders are affected?

11.1 Name of the cancer and the location

11.1 Additional policyholder: Name of the cancer and the location

11.2 Date of diagnosis

11.2 Additional policyholder: Date of diagnosis

11.3 State and grade of cancer

11.3 Additional policyholder: State and grade of cancer

11.4 What symptoms did you have prior to your diagnosis?

11.4 Additional policyholder: What were the symptoms prior to diagnosis?

11.5 Number of lymph nodes involved

11.5 Additional policyholder: Number of lymph nodes involved

11.6 How was your cancer treated?

Medication
Radiation therapy
Hormonal therapy
Surgery
Immunotherapy
Chemotherapy

11.6 Additional policyholder: How was the cancer treated?

Medication
Radiation therapy
Hormonal therapy
Surgery
Immunotherapy
Chemotherapy

Please give further details of treatment eg chemotherapy regime and medication name

Additional policyholder: Please give further details of treatment eg chemotherapy regime and medication name

Duration of treatment

Additional policyholder: Duration of treatment

Date of last treatment

Additional policyholder: Date of last treatment

11.7 Was there any indication of the cancer spreading?

11.7 Additional policyholder: Was there any indication of the cancer spreading?

Please provide details including location(s)

Additional policyholder: Please provide details including location(s)

11.8 Has there been any evidence of recurrence?

11.8 Additional policyholder: Has there been any evidence of recurrence?

Please provide details

11.9 Is there any family history of cancer?

Please provide details

11.10 Are you currently on any medication / treatment?

11.10 Additional policyholder: Are you currently on any medication / treatment?

Please provide names and dosage

Additional policyholder: Please provide names and dosage

11.11 Date you last consulted your physician

11.11 Additional policyholder: Date you last consulted your physician

11.12 If any further policyholders have experienced cancer or related issues please provide full details here

12. Disease or disorder of the breast, kidney, kidney stones, bladder, prostate, abnormal PSA or any other urinary disorder or infection *

Urology medical questionnaire

How many policyholders are affected?

12.1 When did the symptoms first occur / original start date of condition

12.1 Additional policyholder: When did the symptoms first occur / original start date of condition

12.2 What diagnosis was made?

12.2 Additional policyholder: What diagnosis was made?

12.3 What were the first urology symptoms?

12.3 Additional policyholder: What were the first urology symptoms?

12.4 Select if any of these conditions are present

Diabetes
Prostatitis
Polycystic kidney disease
Enlarged prostate
Glomerulonephritis nephrosclerosis
Systemic lupus erythematosus
Other

12.4 Additional policyholder: Select if any of these conditions are present

Diabetes
Prostatitis
Polycystic kidney disease
Enlarged prostate
Glomerulonephritis nephrosclerosis
Systemic lupus erythematosus
Other

Please specify

12.5 Date of last urine analysis, kidney function, PSA test

12.5 Additional policyholder: Date of last urine analysis, kidney function, PSA test

Result

Additional policyholder: Result

12.6 Have any of the following occurred?

Frequent urination
High blood pressure
Cardiovascular disease
Frequent infection
Prolapse

12.6 Additional policyholder: Have any of the following occurred?

Frequent urination
High blood pressure
Cardiovascular disease
Frequent infection
Prolapse

12.7 Have you ever had blood in your urine?

12.7 Additional policyholder: Have you ever had blood in your urine?

Please give details and dates

12.8 Have you ever had kidney stones?

12.8 Additional policyholder: Have you ever had kidney stones?

How were they treated?

Additional policyholder: How were they treated?

12.9 Have you ever been diagnosed as having kidney failure?

12.9 Additional policyholder: Have you ever been diagnosed as having kidney failure?

Please give details and dates

12.10 Have you ever needed dialysis?

12.10 Additional policyholder: Have you ever needed dialysis?

Please give details and dates

12.11 Have you ever been diagnosed with renal (kidney) cancer?

12.11 Additional policyholder: Have you ever been diagnosed with renal (kidney) cancer?

Please give details and dates

12.12 Do you have any tests pending?

12.12 Additional policyholder: Do you have any tests pending?

Please give details and dates

12.13 Are any policyholders currently on any medication or having any treatment?

Policyholder and medication / treatment

Dosage

Frequency

12.14 Have you ever been hospitalised for this condition?

12.14 Additional policyholder: Have you ever been hospitalised for this condition?

Please give details and dates

12.15 Have you ever required emergency treatment for this condition?

12.15 Additional policyholder: Have you ever required emergency treatment for this condition?

Please give details and dates

12.16 If any further policyholders have urology related issues please provide full details here

13. Disease or disorder of the genital or reproductive system, herpes, any sexually transmitted disease, endometriosis, or abnormal pap smear *

Sexually transmitted infections medical questionnaire

How many policyholders are affected?

13.1 When did the symptoms first occur or when was the condition first detected?

13.1 Additional policyholder: When did the symptoms first occur or when was the condition first detected?

13.2 What was the final diagnosis?

13.2 Additional policyholder: What was the final diagnosis?

13.3 Are you currently experiencing any symptoms?

13.3 Additional policyholder: Are you currently experiencing any symptoms?

When did you last have symptoms?

13.4 Does anyone to be covered on the policy have any tests pending?

Please give dates and details

13.5 Has anyone to be covered required any procudures or other treatment for their condition?

Please give dates and details

13.6 Were any follow up visits recommended?

Please give dates and details

13.7 Has anyone been hospitalised for this condition?

Please give dates and details

13.8 Is anyone currently taking any medication for this?

Please give dates and details

13.9 Is anyone currently receiving any other treatment not yet mentioned?

Please give details

14. Been treated for infertility, taken any medication or been advised to get treatment, diagnostic tests or surgery for fertility *

15. Arthritis, rheumatism, gout, TMJ (temporomandibular joint syndrome), any injury to or disease or disorder of the spine, back, jaw, bones, muscles or joints, joint replacement, or chiropractic treatment *

Musculoskeletal medical questionnaire

How many policyholders are affected?

15.1 What is your diagnosis?

15.1 Additional policyholder: What is your diagnosis?

15.2 When were you first diagnosed with this condition?

15.2 Additional policyholder: When were you first diagnosed with this condition?

15.3 How frequent and severe are the symptoms? (state average frequency per month / year)

15.3 Additional policyholder: How frequent and severe are the symptoms? (state average frequency per month / year)

15.4 Do any policyholders have joints affected?

Please specify

15.5 When was your most recent episode of symptoms?

15.5 Additional policyholder: When was your most recent episode of symptoms?

15.6 Have any policyholders ever received physical therapy or had surgery as a result of their condition, or is any planned?

Please give dates and details

15.7 List any limitations in daily activities or any type of physical limitations you currently have from your condition

15.7 Additional policyholder: List any limitations in daily activities or any type of physical limitations you currently have from your condition

15.8 Are any policyholders taking any medication?

Please list name(s), dosage, frequency and who is taking it

15.9 Has any policyholder been hospitalised or had time lost from work due to this condition?

Please give dates and details

15.10 Are you fully recovered from this condition?

15.10 Additional policyholder: Are you fully recovered from this condition?

Please confirm date of discharge from follow up

Additional policyholder: Please confirm date of discharge from follow up

Additional policyholder: Please provide details of ongoing care or follow ups

15.11 If any further policyholders are affected by musculoskeletal issues please provide full details here

16. Pituitary, adrenal or thyroid disorder, lupus, diabetes *

How many policyholders are affected?

16.1 When did the symptoms first occur / original start date of condition

16.1 Additional policyholder: When did the symptoms first occur / original start date of condition

16.2 What diagnosis was made?

16.2 Additional policyholder: What diagnosis was made?

16.3 Do you have a goiter?

16.3 Additional policyholder: Do you have a goiter?

Please confirm what type this is? (if known)

Additional policyholder: Please confirm what type this is? (if known)

16.4 Has anyone had, or is awaiting any surgery for this condition?

Please give dates and details of the surgical procedure

16.5 Has anyone ever had any diagnostic tests / biopsies for this condition or are any planned?

Diagnostic test 1 + policyholder

Diagnostic test 2 + policyholder

Diagnostic test 3+ policyholder

Date performed | test 1

Date performed | test 2

Date performed | test 3

Results | test 1

Results | test 2

Results | test 3

16.6 Please provide details of any past medication or treatment

Please specify which policyholder and include medication / treatment, dosage and frequency.

16.7 What symptoms do you have now?

16.7 Additional policyholder: What symptoms do you have now?

16.8 Is anyone taking any medication now?

Please list the policyholder(s), medication name, dosage and frequency

16.9 How often are you being followed up and by whom?

16.9 Additional policyholder: How often are you being followed up and by whom?

16.10 Has anyone had any complications or has there been any hospitalisation for this condition?

Please provide dates and details

16.11 Are any future tests or treatments planned?

Please provide dates and details

16.12 If any further policyholders are affected please provide full details here

17. Cataracts, glaucoma, other eye disorder, hearing loss, or any ear, nose or throat disorder *

How many policyholders are affected?

17.1 When did the symptoms first occur / original start date of condition

17.1 Additional policyholder: When did the symptoms first occur / original start date of condition

17.2 What diagnosis was made?

17.2 Additional policyholder: What diagnosis was made?

17.3 Are you currently experiencing any symptoms?

17.3 Additional policyholder: Are you currently experiencing any symptoms?

When did you last have symptoms?

Additional policyholder: When did you last have symptoms?

17.4 How often do symptoms occur and how long do they last?

17.4 Additional policyholder: How often do symptoms occur and how long do they last?

17.5 Have you ever had diagnostic tests / biopsies for this condition?

17.5 Additional policyholder: Have you ever had diagnostic tests / biopsies for this condition?

Please provide details (diagnostic test, date performed and results)

Additional policyholder: Please provide details (diagnostic test, date performed and results)

17.6 Does anyone have any tests pending?

Please provide details and dates

17.7 Date of last medical consultation

17.7 Additional policyholder: Date of last medical consultation

17.8 Please provide details of any past medication or treatment

Include the policyholder, medication/treatment, dosage and frequency

17.9 Is anyone currently being treated?

Please give details

18. Alcoholism, alcohol, drug or substance abuse or dependency *

Please give details

Please state the policyholder(s), how long this has been an issue, how many units / substabces are consumed per week and details of any medical treatments or hospital admissions.

19. Acquired Immune Deficiency Syndrome (AIDS), AIDS-Related Complex (ARC), HIV Positive or other immune disorders *

Immune system disorders medical questionnaire

How many policyholders are affected?

19.1 When did symptoms first occur / original start date of condition

19.1 Additional policyholder: When did symptoms first occur / original start date of condition

19.2 What diagnosis was made?

19.2 Additional policyholder: What diagnosis was made?

19.3 Are you currently experiencing any symptoms?

19.3 Additional policyholder: Are you currently experiencing any symptoms?

When did you last have symptoms?

Additional policyholder: When did you last have symptoms?

19.4 How often do symptoms occur and how long do they last?

19.4 Additional policyholder: How often do symptoms occur and how long do they last?

19.5 Please list any diagnostic tests anyone has had carried out for this condition

Include the policyholder(s), test, date performed and the results.

19.6 Does anyone have any tests pending?

Please give details and dates

19.7 Date of last medical consultation

19.7 Additional policyholder: Date of last medical consultation

19.8 Please provide details of past treatment

Policyholder + Name of immune system treatment 1

Policyholder + Name of immune system treatment 2

Policyholder + Name of immune system treatment 3

Policyholder + Name of immune system treatment 4

Policyholder + Name of immune system treatment 5

Policyholder + Name of immune system treatment 6

Dosage | treatment 1

Dosage | treatment 2

Dosage | treatment 3

Dosage | treatment 4

Dosage | treatment 5

Dosage | treatment 6

19.9 Has anyone ever been hospitalised for this condition?

Please give dates and details

19.10 Has anyone ever required emergency treatment for this condition?

Please give dates and details

19.11 Is anyone currently being treated for this condition?

Please provide details of all treatments / medications

19.12 If any further policyholders are affected please provide full details

20. Physical defect, infirmity or congenital illness *

Please give details

Please state the condition, the policyholder affected, symptoms and any treatment past or present.

21. Prosthesis, implant, monitoring device or internal fixation (ie. pins, plates or screws) *

Please give details

Please state the condition, the policyholder affected, symptoms and any treatment past or present.