Permanent Residence address in full:

* Daily cigarette’s consumption:  
*Daily alcohol's consumption: 

Heart or circulatory disorders, eg high blood pressure, stroke, chest pain, heart
Yes    No  

Respiratory or lung trouble, eg asthma, bronchitis, persistent cough, tuberculosis?
Yes   No

Disorders of the digestive system, gall bladder or liver, eg duodenal ulcer, bleeding from the bowel, hepatitis?
Yes   No

Disease or disorder or infection of the Kidneys, bladder or reproductive organs, eg: protein or blood in the urine, stones, prostatitis, venereal disease, bilharzias?
Yes   No

Nervous, neurological or mental complaint, e.g. fits, epilepsy, blackouts, persistent headaches, paralysis, anxiety state, depression?
Yes   No

Ear, eye, nose, throat or skin disorders, e.g. ear discharge, defective vision, recurrent tonsillitis, porphyria, psoriasis, dermatitis?
Yes   No

Disorders or disease of muscles, bones, joints, limbs or spine, eg rheumatism arthritis, gout, slipped disc, other back or neck troubles?
Yes   No

Diabetes, sugar in urine, blood or spleen disorders, thyroid or other glandular
disorders?
Yes   No

Cancer, leukemia, tumor or growth of any kind?  
Yes   No

Are any medicines or drugs currently prescribed for you, or are you receiving any medical or psychiatric treatment or advice or awaiting surgery?
Yes   No

Have you ever received, or do you expect to receive, any advice, counseling, treatment or blood tests in connection with AIDS, HIV, or an HIV related disorder or any sexually transmitted disease including hepatitis B? 
Yes   No

Have you ever been counseled or treated in connection with alcohol or drugs?  
Yes   No

Has any member of your immediate family suffered from cancer, diabetes, stroke, kidney disease, multiple sclerosis, heart disease, high blood pressure or any hereditary disease before the age of 65? If yes, please provide full details, including the family member and their age at diagnosis 
Yes   No
Details if yes:

I declare that I have read and understood the important notes within this application and that all the statements made by me are true and complete to the best of my knowledge and belief and I have disclosed all relevant information  concerning this application whether or not covered by the questions in this application form or any supplementary questionnaires which might influence the company’s decision concerning this application  including whether to assume risk and the amount of premiums.

I will disclose to the company any changes to the information given in this application which occur following the completion of this application but prior to the receipt by me of an acceptance letter /the contract documentation.

I irrevocably consent to the company seeking from any doctor, hospital, medical institution or other person, information which may be related to my occupation, physical or mental health, including the results of any test, and I authorize the giving of such information.

This authorization shall remain in force after my death.