Questionnaire – Cholesterol
Name
Proposal number
Important information for customers
Before completing this questionnaire it is important that you read this statement, as you will be required
to sign a declaration stating that you understand and agree to the following:
That if you do not answer the questions honestly and completely, Zurich Life may not pay any claim.
It is vital that you answer all questions fully as Zurich Life will not necessarily obtain any medical reports
from your doctor in respect of the answers given in this form.
Zurich Life may accept or provide terms based on your answers alone.
The information requested below is to enable Zurich Life make a decision in some instances without
having to request a report from your General Practitioner (GP). If some of the answers are unknown to
you please try to obtain this information from your GP.
If you are in doubt about this declaration please refer to your Financial Adviser or Zurich Life
___________________________________________________________________________________________
Cholesterol
1. When were you found to have high cholesterol?
2. What was your cholesterol level at the time?
3. Have you been on treatment for this?
□ Yes
□ No
If Yes, what is this? Please give drug names, the date prescribed and, if you stopped taking it,
when?
4. Are you having any treatment now? If so, describe what this is.
5. When were the last two occasions on which your cholesterol was checked?
If Yes, what was the test and what were the results?
6. What were the cholesterol readings on those occasions?
7. Apart from blood tests, have you had any investigations of your heart or circulatory
system (such as an ECG or other tests)?
□ Yes
□ No
If Yes, please give details and the results if you know them.
8. Have you been told you have or have had any other medical conditions related to high
cholesterol? (Examples could be raised blood sugar or triglyceride levels, or heart or
circulatory problems)
□ Yes
□ No
If Yes, please give details.
9. Who has been managing your condition?
□ Your GP
□ Hospital or clinic or specialist
□ Both
Declaration
I declare that the answers to the above questions are true and complete (including any statements
written down for me).
I have read and understood the 'important information for customer' notice on page one of this form
and understand that failure to give true and complete answers to the above questions could result in
Zurich Life rejecting all or part of any claim that may arise.
I agree that this declaration shall be incorporated with and form part of the original application form.
Signature of the life insured _____________________
Date _____________________