FirstChoice – High Blood Pressure Questionnaire Supplementary Personal Statement Full name of Life to be Insured Date of birth of Life to be Insured Account number / / Questions should be completed in respect of the Life to be Insured 1 Date condition first started / / 2 Date condition ceased / / or Ongoing 3 What caused this condition? 4 Have you ever taken medication for this condition? No Yes If ‘Yes’: Please provide us with the following information: a Name and dosage b Are you still taking medication? No Go to i below Yes If ‘No’: i When did you cease taking medication? / / 5 Is your blood pressure regularly monitored by your doctor? No Yes 6 Date of last blood pressure reading / / 7 Result of last blood pressure reading, e.g. 130/80? 8 Does your usual doctor have knowledge of this condition? No Yes If ‘No’: Please provide the following details: Name of doctor Address of doctor Phone number of doctor Fax number of doctor ( ) ( ) I confirm that the above information is true, correct and complete. Signature of Life to be Insured Date / / Please send completed form to: Colonial First State, Reply Paid 27, Sydney NSW 2001. 002-377 110106 Page 1 of 1 CommInsure is a registered business name of The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).