KBIS Personal Accident Medical Questionnaire

KBIS Medical Questionnaire

This questionnaire should be completed by the policyholder when medical conditions, injuries or other problems have been declared on the KBIS proposal form. This form allows you to declare full details for up to 5 medical conditions/injuries. If you need to make more than 5 declarations please complete this form again.

If you are unsure about whether you should complete this form please contact KBIS by telephoning 0345 2302323 (Option 5) or by sending an email to liability@kbis.co.uk. You must take care in answering all of the following questions, which are relevant to KBIS in providing this insurance and setting the terms and premium. If you do not understand the questions or the nature of the information required please seek guidance from KBIS.

Failure to provide information or the provision of incomplete or inaccurate information may result in the loss of cover or revised terms and/or premium or it may affect any claim you make under this insurance.

Policyholder's Name*

Policyholder's Address*

Postcode*

Telephone Number*

Email Address (We use this information to send you a copy of the information contained within this questionnaire)*

Declaration 1

1. Date of Occurrence: (if more than one episode, please give all dates)*

2. Diagnosis: (suspected or confirmed)*

3. Please give details of any treatment/medication received:*

4. Please give all periods off work. If no time was taken off work, give the duration of the problem.*

5. Is any further problem or treatment anticipated?*

YesNo

If yes, please give further details*

6. If you answered no to question 5, please confirm if a full recover has now been made and that there are no residual problems:*

I confirm a full recovery has been made and there are no residual problemsA full recovery has NOT been made, or there are residual problems

If you haven"t recovered or have residual problems, please provide details:*

Do you need to make another declaration?

YesNo

Declaration 2

1. Date of Occurrence: (if more than one episode, please give all dates)*

2. Diagnosis: (suspected or confirmed)

3. Please give details of any treatment/medication received:*

4. Please give all periods off work. If no time was taken off work, give the duration of the problem.*

5. Is further treatment anticipated?*

YesNo

If yes, please give further details*

6. If you answered no to question 5, please confirm if a full recovery has now been made and that there are no residual problems*

I confirm a full recovery has been made and there are no residual problemsA full recovery has NOT been made, or there are residual problems

If you haven"t recovered or have residual problems, please detail them:*

Do you need to make another declaration?*

YesNo

Declaration 3

1. Date of Occurrence: (if more than one episode, please give all dates)*

2. Diagnosis: (suspected or confirmed)

3. Please give details of any treatment/medication received:*

4. Please give all periods off work. If no time was taken off work, give the duration of the problem.*

5. Is further treatment anticipated?*

YesNo

If yes, please give further details*

6. If you answered no to question 5, please confirm if a full recovery has now been made and that there are no residual problems*

I confirm a full recovery has been made and there are no residual problemsA full recovery has NOT been made, or there are residual problems

If you haven"t recovered or have residual problems, please detail them:*

Do you need to make another declaration?*

YesNo

Declaration 4

1. Date of Occurrence: (if more than one episode, please give all dates)*

2. Diagnosis: (suspected or confirmed)

3. Please give details of any treatment/medication received:*

4. Please give all periods off work. If no time was taken off work, give the duration of the problem.*

5. Is further treatment anticipated?*

YesNo

If yes, please give further details*

6. If you answered no to question 5, please confirm if a full recovery has now been made and that there are no residual problems*

I confirm a full recovery has been made and there are no residual problemsA full recovery has NOT been made, or there are residual problems

If you haven"t recovered or have residual problems, please detail them:*

Do you need to make another declaration?*

YesNo

Declaration 5

1. Date of Occurrence: (if more than one episode, please give all dates)*

2. Diagnosis: (suspected or confirmed)

3. Please give details of any treatment/medication received:*

4. Please give all periods off work. If no time was taken off work, give the duration of the problem.*

5. Is further treatment anticipated?*

YesNo

If yes, please give further details*

6. If you answered no to question 5, please confirm if a full recovery has now been made and that there are no residual problems*

I confirm a full recovery has been made and there are no residual problemsA full recovery has NOT been made, or there are residual problems

If you haven"t recovered or have residual problems, please detail them:*

Do you need to make another declaration?*

YesNo

To continue making further declarations please first submit this form and then complete an additional form.

Proposers Declaration

I declare that the information disclosed in this questionnaire, is to the best of my knowledge and belief both accurate and complete. I/we have taken care not to make any misrepresentation in the disclosure of this information and understand that all information provided is relevant to the acceptance and assessment of this insurance, the terms on which it is accepted and the premium charged.

I confirm the above statement:*

YesNo

Electronic Signature

By completing the section below you acknowledge that you are electronically signing this document and have complied with the requirements set out above.

Name of Person completing this questionnaire

Date of completion

Date