PULSE Height Weight

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					Height & Weight
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
Height   security for this policy is Lloyds of London.
                            Weight                  Have you smoked in the last 12 months?


                                 INFORMATION ABOUT YOUR MEDICAL CONDITION

Has your weight changed recently and if so,
how?




Do you suffer from any conditions in relation to
your weight, e.g high blood pressure or
diabetes? If so, please give details.




Have you consulted any specialists or attended
clinics in relation to your weight?



Please give the name and dosage of any
medication you are currently taking.




Do you have any surgery planned, e.g a gastric
band operation? If so, please give date of
surgery


Are there any other medical conditions or any
other area that could identify the applicant as
non-standard, e.g occupation, sports? Please
give details




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

				
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