Chronic Fatigue
Contact name:
IFA company name:
Telephone number:
Email:
GENERAL INFORMATION
Full name of life proposed Sum Assured
Gender Period of Policy
Date of Birth Level/Decreasing Term Assurance
The security for this policy is Lloyds of London.
Height Weight Have you smoked in the last 12 months?
INFORMATION ABOUT YOUR MEDICAL CONDITION
What was the mode of onset of the illness?
When did this occur?
What has been the course of the illness? Please
give symptomatology and relevant dates.
Prior to the diagnosis of chronic fatigue
syndrome, were other possible diagnoses
considered?
Please report the results of all investigations,
including relevant dates.
What treatment has been/is being given, and
what is the expected future management?
Has there been a complete recovery with no
residual physical deficit or mental illness
whatsoever? If so, when did this occur?
Have you any other information or comments? A
sight of hospital/specialists reports would be
valuable.
Signed (client or IFA): Date:
Pulse Insurance Limited
Authorised and Regulated by the Financial Services Authority
6 Oxford Court, St James Road, Brackley, Northants, NN13 7XY
Tel: 01280 841430 Fax: 01280 702977 E-mail: admin@pulse-insurance.co.uk Website: www.pulse-insurance.co.uk