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Dear

Further to your recent communication with Chase Templeton please see below a list of questions that will enable us to carry out a full market review of your medical insurance.

Your answers will enable us to research the market and ensure you have the most appropriate policy to suit your needs and budget. Therefore, please remember to consider everyone you wish to cover including yourself when answering these questions.

If at any point you decide you would prefer to discuss these questions over the phone, then please do not hesitate to telephone me on 0800 018 3633.

Before you start...

Please could you provide your postcode and Dates Of Birth for all persons to be covered?

Insurance Type

1. Do you currently have medical insurance?

General Questions

1: What level of cover are you looking for? Comprehensive, Mid-Range or Budget?
2: Which benefits would you like to be included in your quote:
Physiotherapy Mental Health Dental & Optical Other
Please Include Details
3: Would you be happy for your policy to include an excess?
4: Do you have a preference for any particular private hospital?
5: Would you be able to confirm your budget?

Medical Questions

1: In the last 12 months has anyone to be covered on the policy had any consultations or treatments which have been privately self-paid or paid for by the NHS?
Additional details
2: Have you or anyone to be covered ever had treatment or advice for any of the following:
Heart condition or other heart problem
Stroke
Cancer
Diabetes
Mental illness, including depression that has required referral to a specialist
Surgical procedures/arthroscopies (key hole surgery) for joints and back
Osteoarthritis or inflammatory arthritis
Disease of the prostate associated with an abnormal PSA result
3: Have you or anyone to be covered received any medical treatment or undergone any medical investigations in the last 5 years? If so please provide details.
Additional details
4: Are you or anyone to be covered taking any regular medication or having regular medical advice for any condition? If so please provide details.
Additional details
5: Are you aware of any other medical conditions or symptoms that may require treatment or advice in the future? If so please provide details.
Additional details
6: Do you or any other person to be covered have any appointments, tests or treatments planned, pending or booked with a GP, specialist or hospital? If so please provide details.
Additional details
7: Are any adults to be covered smokers? If yes please specify.
Additional details
8: Please provide details of your occupation, including whether you are self-employed.

General Questions

1: Do you still require a similar level of cover? You can increase or decrease your level of cover and your excess but, this can only be completed at renewal.
2: Do you have a preference for Hospitals? Do you need the Central London Hospitals?

Medical Questions

1: Have you or anyone to be covered used your healthcare policy in the last year? If so please provide details.
What for?
2: In the last 12 months has anyone to be covered on the policy had any consultations or treatments which have been privately self-paid or paid for by the NHS?
Additional details
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3: When did you last use the policy if not in the last 12 months? Please provide details.
4: Have you or anyone to be covered ever had treatment or advice for any of the following:
Heart condition or other heart problem
Stroke
Cancer
Diabetes
Mental illness, including depression that has required referral to a specialist
Surgical procedures/arthroscopies (key hole surgery) for joints and back
Osteoarthritis or inflammatory arthritis
Disease of the prostate associated with an abnormal PSA result
5: Have you or anyone to be covered received any medical treatment or undergone any medical investigations in the last 5 years? If so please provide details.
Additional details
6: Are you or anyone to be covered taking any regular medication or having regular medical advice for any condition? If so please provide details.
Additional details
7: Are you aware of any other medical conditions or symptoms that may require treatment or advice in the future? If so please provide details.
Additional details
8: Do you or any other person to be covered have any appointments, tests or treatments planned, pending or booked with a GP, specialist or hospital? If so please provide details.
Additional details
9: Are any adults to be covered smokers? If yes please specify.
Additional details
10: Please provide details of your occupation, including whether you are self-employed.

Declaration

The information supplied above will help your Chase Templeton adviser find the most appropriate policy for your needs from everything the UK market has to offer.

To ensure these quotes are accurate and suitable for your needs please tick this box to confirm you are happy with the accuracy of the details you have provided.

If you need to change any details at any time please do not hesitate to telephone your adviser on 0800 018 3633.

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