The Protection PlatformData Capture Form

The Protection PlatformData Capture Form
Personal details
Full name
Date of birth

MonthDayYear
Gender
Address
Email
Telephone
General
Q How tall are you?
This can be in feet and inches or centimetres
Q How much do you weigh?
This can be either stones or pounds. Female only – if you’re pregnant, please tell us how much you weigh before you were pregnant
Q What is your job?
This needs to be your main job (e.g. the one you spend most time doing)
Q How much did you earn in the last year?
This is your taxable income. Include overtime, commission and bonuses but do not include income from investments or any income that would continue if you can’t work. If you’re selfemployed, please tell us your taxable income (e.g. earnings after costs and before tax)
Q Do you have another job?
Q Are you currently off work, workingreduced hours or altered your dutiesto sickness or injury?
Smoking
Q What is your average daily consumption?
Cigarettes
Cigars
Tobacco
Q Which of the following best describes you?
Family health
Q Have your birth parents, brothers, or sistershad any of these before they were 65?
Q In the last 5 years have you had any of these?
Q In the last 5 years have you hadany of these?
Q In the last 5 years have you hadany of these?
Mental health
Q In the last 5 years have you had any of these?
Q Have you ever had any of these?
Q Have you ever:
Physical health
Q Have you ever had any of these?
General health
Q Have any of these applied to you in thelast 3 years?
Q Have you had any of these in the last 3months, even if you haven’t seen a doctor?
Q Do any of these apply to you?
Lifestyle
Q How many of these do you drink per week?
Pints of beer, lager or cider
Glasses of wine
Measures of spirits
Other alcoholic drinks
Q Have any of these applied to you?
Q Are you involved in any of these?
Q Have any of these applied to you?
Q Have you lived, worked or travelled outsidethe UK or European Union in the last 5 years,or do you have any plans to do so in thenext year?
Q How many years have you lived in the UK?
By ‘lived in the UK’ we mean you must have lived in the UK for more than 9 months each year, paid UK taxes, had your main home here and have financial ties (e.g. bank accounts or mortgage)
Q Do you have existing Life insuranceor are you applying for any other Lifeinsurance?
Q Do you have existing Income Protectioninsurance or are you applying for anyother Income Protection insurance?
Q Do you have existing Critical Illnessinsurance or are you applying for anyother Critical Illness insurance?
Additional information
Q Please confirm your GP Surgery name?
Should be Empty:

The Protection PlatformData Capture Form

Personal details

General

Smoking

Family health

Mental health

Physical health

General health

Lifestyle

Additional information