HIV Life Assurance Application Form


 Single life   Joint life
Which type of life assurance do you need? An explanation is provided on our Life Assurance Explanation page. If you are not sure, please consult with an Idependent Financial Advisor as, by law, we are not allowed to offer advice.


 Level of cover    Monthly premium


Please enter first person details

CONTACT DETAILS

 Female   Male
 Yes    No

ABOUT YOU

   Meters    Feet & Inches
   Kg    lbs/ozs
 Yes    No
 Yes    No

PREVIOUS COVER

 Yes    No
 Yes    No

HAZARDOUS ACTIVITIES

 Yes    No
 Yes    No
 Yes    No
 Yes    No

DETAILS ABOUT HIV

If you've had HIV-related illnesses or symptoms, such as pneumonia, diarrhoea, night sweats, etc please provide details
What treatments or investigations have you had, including dates?
What medication are you currently taking, including its name and quantity?

OTHER HEALTH CONDITIONS - 1

Name of condition, illness or injury
Date diagnosed
Treatments, including dates
Medication, including name and quantity

OTHER HEALTH CONDITIONS - 2

Name of condition, illness or injury
Date diagnosed
Treatments, including dates
Medication, including name and quantity

OTHER HEALTH CONDITIONS - 3

Name of condition, illness or injury
Date diagnosed
Treatments, including dates
Medication, including name and quantity