Existing Policy Holder :  YesNo

Are you in good health with no major health conditions or medication?

Health Conditions:

A.I.D.S or H.I.V. Positive

NoEarly stages - TreatableGiven terminal time frame


NoDoes not drink anymore – over 3 years – no damage to liverDoes not drink anymore – under 3 years – no damage to liverCurrent/In Rehab


NoTakes meds seasonallyTakes meds occasionallyTakes meds daily

Cancer – including

(Tumours or malignant growth, leukaemia, skin cancer,Carcinomas, Hodgkin's disease )

NoCleared for over 3 years – no known damageCleared under 3 years – no known damageCurrent – treatment/meds - TreatableTerminal time frame

Cerebral Palsy

NoMild symptomsSevere symptoms

Diabetes – including

(Type 1 & Type 2)

NoDiet controlledTablet controlledInsulin dependant

Drug Use

NoNot using – over 3 years – no known damageNot using – less than 3 years – no known damageCurrent – intravenous

Epilepsy – including

(Grand Mal, Petit Mal, partial seizures and temporal lobe)

NoNon current – no meds or treatment over 3 yearsCurrent – Petit Mal typeCurrent – Grand Mal type

Heart Conditions – including

(Heart Disease, Angina, Arrhythmia, Endocarditis,Heart attack, Myocarditis,Hypotension)

NoNon current – over 3 years – no known damageHeart Murmur – mild – no meds or treatmentNon current – under 3 years – no known damageCholesterol – taking meds – under control – no other issuesCurrent – taking meds/having treatment

Hepatitis A, B, C, D, E, G

NoHep A – current/clearedHep B – cleared over 3 yearsHep B – current/cleared under 3 yearsHep C – no meds – complete recoveryHep C – current – taking meds/treatmentHep D – would already have Hep B – non terminalHep E – cleared for over 3 yearsHep E – current/cleared under 3 years

High Blood Pressure

NoDiet/weight loss controlled – no medsCaused by stress/traumatic event – meds for short timeCurrent – controlled by meds/treatmentCurrent – Not controlled – taking meds/treatment

Kidney Problems – including

(Infections, Kidney stones and Kidney failure)

NoNon current – over 3 years – no known damageNon current – under 3 years – no known damageCurrent - Dialysis - taking meds/treatmentGiven terminal time frame

Liver Problems – including

(Cirrhosis, liver failure)

NoCleared for over 3 years – no known damageCirrhosis/liver failure – taking meds/treatmentGiven terminal time frame


NoDLE (Discoid Lupus Erythematosus)SLE (Systemic Lupus Erythematosus)


NoNo damage to body that could lead to other complicationsSuffered damage to brain/heart/kidney etc

Mental / Nervous Conditions

(ADHD, schizophrenia,Organic brain syndrome, manic Depressive, anxiety disorders)

NoMilder types – Depression/Anxiety – taking meds & no other illnessADHD – taking medsNon current – no meds/treatmentSchizophrenia/ Bipolar Manic-Depressive - needs medication

Muscular Dystrophy

(All types)

NoMilder typesSerious types


NoCurrent/had attack in last 3 yearsNo attacks for over 3 years – no known damage

Physical & Mental Disabilities

(Including blind, deaf, injuries,Down's Syndrome, Spina Bifida, back and spinal injuries& any other physical or mental disability)

NoPhysical Disabilities - minorMental Disabilities - minorDowns Syndrome – mild – no damage to heartSpina Bifida - no major damage to spinal cordDowns Syndrome – heart problemsSpina Bifida – serious damage to spinal cordPhysical Disabilities – takes meds/treatment – considered seriousMental Disabilities – takes meds/treatment – considered serious

Respiratory Conditions

(COAD, Tuberculosis Cystic fibrosis, Emphysema, Pneumonia, chronic Bronchitis)

NoAsthma – See under AsthmaColds/FluCurrent – taking meds/treatmentGiven terminal time frame

Rheumatic Fever

NoNo reoccurrences in 3 years – no damage to heartWithin the last 3 years – taking meds/treatment


(Also called Cerebral infarct,Cerebrovascular accident ( CVA))

NoNo meds/treatment over 3 years – no known damageNo meds/treatment under 3 years – no known damageCurrent - meds/treatment

Thyroid Problems – including

(Hyper/ hypothyroidism, & Grave's disease)

NoTaking meds – no damage to heart or liverMeds prescribed but does not takeCurrent - Has damage to heart/liver

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