Cystic Fibrosis
Post to:
Freedom Life Insurance
Richmond House
16 -20 Regent Street
Contact name: Cambridge, CB2 1DB
Telephone: 01223 446 915
IFA company name:
Email: life@freedominsure.co.uk
Telephone number: Web: www.freedominsure.co.uk
Email:
GENERAL INFORMATION
Full name of life proposed Sum Assured Preferred Monthly Premium
Gender Period of Policy
Date of Birth Level/Decreasing Term Assurance
The
Height security for this policy is Lloyds of London.
Weight Have you smoked in the last 12 months?
Has your weight If Yes, please provide What is your job? Do you work full time or part
changed by more than details time?
4 lbs over the past 2
years? How much time has been lost
from work due to illness over
the past 2 years?
INFORMATION ABOUT YOUR MEDICAL CONDITION
When was cystic fibrosis diagnosed?
Would you describe your condition as mild,
moderate or severe?
How often do you require hospital treatment
because of a flare up of your condition?
Please provide the date of your last review by
your specialist and what was the outcome?
What is your current lung function if known?
Please give details of your current treatment.
How does your condition affect your ability to
lead a normal life, including the ability to work?
Please give details.
Do you have any associated illnesses?
e.g. diabetes
Signed (client or IFA): Date:
Freedom Insurance Services Limited will only share your details with Pulse Insurance Ltd and their underwriters for the sole purpose of obtaining
life insurance quotations on your behalf. Freedom Insurance Services Limited (Registered in England No. 4399749) is part of the NW Brown
Group Limited and is authorised and regulated by the Financial Services Authority reference number 306536. VAT registration number 897396347