{ "status" : "FAIL", "info" : "clientID:
Name:
Type:Does Not Have Existing Insurance



Before you start...

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


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:


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?


2: Have you or anyone to be covered ever had treatment or advice for any of the following:


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.


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.


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.


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.


7: Are any adults to be covered smokers? If yes please specify.


8: Please provide details of your occupation, including whether you are self-employed.


" }