• Annuity Questionnaire

  • Basic Details Applicant

  • Do you have a partner who will be part of any annuity purchased?
  • Date of Birth (55 Plus only)*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Retirement Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Intended Retirement Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Is this form being completed by the Power of Attorney or another person other than the applicant?

  • Joint Annuitant Details

  • Partner's Date of Birth
     - -
    2 digit day, 2 digit month, 4 digit year
  • Partner has same address and residential status as applicant?
  • Partner Retirement Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • Partner Intended Retirement Date
     - -
    2 digit day, 2 digit month, 4 digit year

  • Measurements

  • Unit

  • Drinking

  • Smoking

  • When did you start?
     - -
    2 digit day, 2 digit month, 4 digit year
  • When did you stop?
     - -
    2 digit day, 2 digit month, 4 digit year

  • Partner's Measurements

  • Partner Unit

  • Drinking

  • Smoking

  • When did your partner start?
     - -
    2 digit day, 2 digit month, 4 digit year
  • When did your partner stop?
     - -
    2 digit day, 2 digit month, 4 digit year

  • Annuity Options Required

  • Your Existing Pensions

  • Medical Conditions

  • Do you have any medical conditions
  • Please select each condition

  • High Cholesterol

  • Date Diagnosed
     - -
    2 digit day, 2 digit month, 4 digit year
  • Date of last reading
     - -
    2 digit day, 2 digit month, 4 digit year
  • Date of Previous reading
     - -
    2 digit day, 2 digit month, 4 digit year

  • High Blood Pressure

  • Heart Condition

  • Date of Diagnosis
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is this condition Ongoing
  • Date of most recent stress (exercise) ECG testing (eg using a bicycle or treadmill)
     - -
    2 digit day, 2 digit month, 4 digit year
  • Have you had surgery for this condition?

  • Condition Details

    Does this heart condition CURRENTLY affect you in any of the following ways?

  • Diabetes

  • Date Diagnosed
     - -
    2 digit day, 2 digit month, 4 digit year
  • Have you ever been hospitalised as a result of your diabetes?
  • When were you last hospitalised?
     - -
    2 digit day, 2 digit month, 4 digit year
  • Do you suffer from any of the following diabetic complications?

  • Cancer, Leukaemia, Hodgkin's Disease, lymphoma, Growth or Tumour

  • First Diagnosed Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • When was your last tumour follow-up appointment with your treating doctor/hospital consultant?
     - -
    2 digit day, 2 digit month, 4 digit year
  • Have you now been discharged?
  • Has there been any recurrence in the same location?
  • Please tick if you have one of the following conditions
  • Current PSA date recorded
     - -
    2 digit day, 2 digit month, 4 digit year
  • Pre-treatment PSA date recorded
     - -
    2 digit day, 2 digit month, 4 digit year
  • Gleason Score date recorded
     - -
    2 digit day, 2 digit month, 4 digit year

  • Current Medications

  • Treatments

    Did you have, or are you due to have, any of the following as a result of your tumour or malignant condition (eg Leukaemia)?
  • Surgery
  • Surgery date started
     - -
    2 digit day, 2 digit month, 4 digit year
  • Surgery date ended
     - -
    2 digit day, 2 digit month, 4 digit year
  • Chemotherapy
  • Chemotherapy date started
     - -
    2 digit day, 2 digit month, 4 digit year
  • Chemotherapy date ended
     - -
    2 digit day, 2 digit month, 4 digit year
  • Radiotherapy
  • Radiotherapy date started
     - -
    2 digit day, 2 digit month, 4 digit year
  • Radiotherapy date ended
     - -
    2 digit day, 2 digit month, 4 digit year
  • Bone marrow transplant
  • Bone marrow transplant date started
     - -
    2 digit day, 2 digit month, 4 digit year
  • Bone marrow transplant date ended
     - -
    2 digit day, 2 digit month, 4 digit year
  • Hormone therapy
  • Hormone therapy date started
     - -
    2 digit day, 2 digit month, 4 digit year
  • Hormone therapy date ended
     - -
    2 digit day, 2 digit month, 4 digit year
  • Other treatment (eg. BCG, HIFU, Immunotherapy)
  • Other treatment date started
     - -
    2 digit day, 2 digit month, 4 digit year
  • Other treatment date ended
     - -
    2 digit day, 2 digit month, 4 digit year

  • Additional Information

  • Stroke

  • Date of Occurence
     - -
    2 digit day, 2 digit month, 4 digit year

  • If multiple occurences or types of stroke, please provide details in additional notes below

  • Ongoing Problems

  • Activities of Daily Living (ADL) questionnaire

    Please select each of the following that most closely reflects your current condition:

  • Respiratory/lung disease

  • Date of Diagnosis
     - -
    2 digit day, 2 digit month, 4 digit year

  • Additional information

  • Do any of the following apply?

  • Multiple Sclerosis

  • Date Diagnosed
     - -
    2 digit day, 2 digit month, 4 digit year

  • Do you have, or have you had, any of the following in relation to your multiple sclerosis?

  • Activities of Daily Living (ADL) questionnaire

    Please select each of the following that most closely reflects your current condition:

  • Neurological disease

  • Date of diagnosis?
     - -
    2 digit day, 2 digit month, 4 digit year

  • Do you have, or have you had, any of the following symptoms in relation to your neurological condition?

  • Any other serious illness or condition

  • When were you first diagnosed with this condition?
     - -
    2 digit day, 2 digit month, 4 digit year
  • When did you last experience symptoms for this condition?
     - -
    2 digit day, 2 digit month, 4 digit year
  • When did you last receive medication/treatment for this condition?
     - -
    2 digit day, 2 digit month, 4 digit year

  • Partner Medical Conditions

  • Does your partner have any medical conditions?
  • Please select each condition your partner suffers
  • Partner has same Doctor as applicant?

  • Partner High Cholesterol

  • Date Diagnosed
     - -
    2 digit day, 2 digit month, 4 digit year
  • Date of last reading
     - -
    2 digit day, 2 digit month, 4 digit year
  • Date of Previous reading
     - -
    2 digit day, 2 digit month, 4 digit year

  • Partner High Blood Pressure

  • Partner Heart Condition

  • Date of Diagnosis
     - -
    2 digit month, 2 digit day, 4 digit year
  • Is this condition Ongoing
  • Date of most recent stress (exercise) ECG testing (eg using a bicycle or treadmill)
     - -
    2 digit day, 2 digit month, 4 digit year
  • Have you had surgery for this condition?

  • Condition Details

    Does this heart condition CURRENTLY affect you in any of the following ways?

  • Partner Diabetes

  • Date Diagnosed
     - -
    2 digit day, 2 digit month, 4 digit year
  • Have you ever been hospitalised as a result of your diabetes?
  • When were you last hospitalised?
     - -
    2 digit day, 2 digit month, 4 digit year
  • Do you suffer from any of the following diabetic complications?

  • Partner Cancer, Leukaemia, Hodgkin's Disease, lymphoma, Growth or Tumour

  • First Diagnosed Date
     - -
    2 digit day, 2 digit month, 4 digit year
  • When was your last tumour follow-up appointment with your treating doctor/hospital consultant?
     - -
    2 digit day, 2 digit month, 4 digit year
  • Have you now been discharged?
  • Has there been any recurrence in the same location?
  • Please tick if you have one of the following conditions
  • Current PSA date recorded
     - -
    2 digit day, 2 digit month, 4 digit year
  • Pre-treatment PSA date recorded
     - -
    2 digit day, 2 digit month, 4 digit year
  • Gleason Score date recorded
     - -
    2 digit day, 2 digit month, 4 digit year

  • Current Medications

  • Treatments

    Did you have, or are you due to have, any of the following as a result of your tumour or malignant condition (eg Leukaemia)?
  • Surgery
  • Surgery date started
     - -
    2 digit day, 2 digit month, 4 digit year
  • Surgery date ended
     - -
    2 digit day, 2 digit month, 4 digit year
  • Chemotherapy
  • Chemotherapy date started
     - -
    2 digit day, 2 digit month, 4 digit year
  • Chemotherapy date ended
     - -
    2 digit day, 2 digit month, 4 digit year
  • Radiotherapy
  • Radiotherapy date started
     - -
    2 digit day, 2 digit month, 4 digit year
  • Radiotherapy date ended
     - -
    2 digit day, 2 digit month, 4 digit year
  • Bone marrow transplant
  • Bone marrow transplant date started
     - -
    2 digit day, 2 digit month, 4 digit year
  • Bone marrow transplant date ended
     - -
    2 digit day, 2 digit month, 4 digit year
  • Hormone therapy
  • Hormone therapy date started
     - -
    2 digit day, 2 digit month, 4 digit year
  • Hormone therapy date ended
     - -
    2 digit day, 2 digit month, 4 digit year
  • Other treatment (eg. BCG, HIFU, Immunotherapy)
  • Other treatment date started
     - -
    2 digit day, 2 digit month, 4 digit year
  • Other treatment date ended
     - -
    2 digit day, 2 digit month, 4 digit year

  • Additional Information

  • Partner Stroke

  • Date of Occurence
     - -
    2 digit day, 2 digit month, 4 digit year

  • If multiple occurences or types of stroke, please provide details in additional notes below

  • Ongoing Problems

  • Activities of Daily Living (ADL) questionnaire

    Please select each of the following that most closely reflects your current condition:

  • Partner Respiratory/lung disease

  • Date of Diagnosis
     - -
    2 digit day, 2 digit month, 4 digit year

  • Additional information

  • Do any of the following apply?

  • Partner Multiple Sclerosis

  • Date Diagnosed
     - -
    2 digit day, 2 digit month, 4 digit year

  • Do you have, or have you had, any of the following in relation to your multiple sclerosis?

  • Activities of Daily Living (ADL) questionnaire

    Please select each of the following that most closely reflects your current condition:

  • Partner Neurological disease

  • Date of diagnosis?
     - -
    2 digit day, 2 digit month, 4 digit year

  • Do you have, or have you had, any of the following symptoms in relation to your neurological condition?

  • Partner any other serious illness or condition

  • When were you first diagnosed with this condition?
     - -
    2 digit day, 2 digit month, 4 digit year
  • When did you last experience symptoms for this condition?
     - -
    2 digit day, 2 digit month, 4 digit year
  • When did you last receive medication/treatment for this condition?
     - -
    2 digit day, 2 digit month, 4 digit year

  • Any Other Information and declaration

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  • I/We declare that the information and statements provided
    above are true and I/we have taken reasonable care to ensure
    that my/our answers to the questions asked are correct. I/We
    understand that if any information provided by me/us is
    subsequently found to be inaccurate the policy may be amended
    or cancelled in accordance with the Consumer Insurance
    (Disclosure and Representations) Act 2012. I understand that
    this may mean the benefits payable to me/ us are reduced
    and in some instances the policy may be cancelled.


    I/We agree that the Provider may obtain medical information
    from any doctor who, at any time, has attended me/us, about
    anything that affects my/our physical or mental health and/or
    any insurance office to which a proposal has been made on
    my/our life and I/we authorise the giving of such information.
    This consent shall remain valid throughout the duration of
    the insurance and after my/our death unless I/we advise the
    Provider otherwise.


    I/We agree that the Provider may apply for medical evidence.
    I/We authorise the Provider to pass medical information to
    any medical officer on the Provider’s behalf.
    I/We accept the Provider will use the information I/we give for
    administration, underwriting, claims, research and statistical
    purposes. I/We agree the Provider may pass information about
    my/our physical or mental health or condition to medical
    practitioners and reinsurers.


    I/We agree that a copy of this declaration and consent can be
    treated as the original.


    I/We agree to the Provider processing my/our medical data in
    accordance with the Annuityhelp Direct Privacy Notice, and the

    Retirement Health Form Privacy Notice  


    I/We understand that I/we must inform the Provider without
    delay if there is a change to my/our health or circumstances
    before the commencement of the policy. I/We understand
    that failure to do so may result in amendment or cancellation
    of the policy in accordance with the Consumer Insurance
    (Disclosure and Representations) Act 2012.

    I/We have been duly notified of my/our rights under the
    Access to Medical Information legislation
    governing access to medical records.


    I/We understand that the Provider may pass the information
    to third parties for the prevention or detection of fraud,
    enabling assets to be rightfully claimed or where required
    by law or regulation.

  • YOU: If a medical report is requested, do you wish to see a copy of this before it is sent to the annuity provider? (this would delay the underwriting)*
  • PARTNER: If a medical report is requested, do you wish to see a copy of this before it is sent to the annuity provider? (this would delay the underwriting)*
  • Should be Empty: