Singapore Life Insurance Underwriting - Adult

A. FAMILY HISTORY
1. Have either of your natural parents or any siblings died or suffered from cancer, heart disease, stroke, high blood pressure, diabetes, kidney disease, mental disorder, tuberculosis or any hereditary disease? If yes, please state condition, relationship, age at onset and age at death.
YES | NO

If yes, please provide details below:
Relationship: Condition: Age At Onset: Age At Death:

B. MEDICAL AND UNDERWRITING QUESTIONS
1. (a)Do you have any insurance policy(ies) which have been withdrawn/surrendered/lapsed over the last twelve (12) months? If yes, please state name of company, sum assured, issue date of policy.
YES | NO

(b) Has any proposal for life or health insurance on your life to this or any other insurer ever been declined/postponed/accepted at other than normal terms?
YES | NO

2. Do you engage or have any intention of engaging in any sport or occupation of a dangerous nature e.g. scuba/skin diving, motor-racing, military/private flying other than as a fare-paying passenger etc.?
YES | NO

3. Have you, during the past five years, ever stayed in or travelled to a country(ies) different from where you live at present? If yes, please state the countries and number of times per year.
YES | NO

4. Are you now receiving or considering to receive medical treatment from a doctor, or intending to consult any doctor for any reason? If yes, please state the nature of treatment and provide name & address of doctor.
YES | NO

5. In the past three years, have you ever had any tests done such as X-ray, ultrasound, CT scan, biopsy, electrocardiogram (ECG), blood or urine test?
YES | NO

6. (a) Have you ever smoked during the last twelve(12) months? If yes, please state the number of sticks per day. How many years have you been smoking?
YES | NO

(b) Have you ever been advised to stop smoking by the doctor?
YES | NO

7. Have you ever taken additive drugs/narcotics or been treated for alcoholism or drug addiction?
YES | NO

8. Do you consume beer, wine or other alcoholic beverages? If yes, please state the type of alcoholic beverages and average weekly consumption.
YES | NO

9. Have you ever had or been told to have or been treated for:
(a) Diabetes, thyroid disorders or any other endocrine disorders?
YES | NO

(b) Asthma, persistent cough, coughing with blood, pneumonia, tuberculosis, chest or breathing complaints/discomfort, or any other lung disorders?
YES | NO

(c) Raised cholesterol, high blood pressure, heart attack, heart murmur, mitral valve prolapse or other heart valve disorders, breathlessness, irregular/fast heart rate, chest discomfort/pain, disease of or any other disorders of the heart or blood vessels?
YES | NO

(d) Epilepsy, fits, stroke, paralysis, weakness of limbs, prolonged headache, unconsciousness, nervous breakdown, depression, or any other nervous/mental disorders?
YES | NO

(e) Gastritis, stomach/duodenal ulcer, blood in the stools, fistula, piles, or any stomach/bowel disorders?
YES | NO

(f) Jaundice, hepatitis B carrier or any form of hepatitis, liver disorder or gall bladder disorder?
YES | NO

(g) Blood, protein/sugar in the urine, kidney stones, infection, or any other disorders of the kidney, bladder, or genital organs?
YES | NO

(h) Slipped disc, gout, arthritis, pain/deformity/disorders of the muscles, spine, limbs, or joints, or severe injury?
YES | NO

(i) Anaemia, any other disorders of the blood, advised to abstain from donating blood, or received blood transfusion or blood products on account of haemophilia or any other reasons?
YES | NO

(j) Ear discharge, nose bleeds, double vision, impaired sight or hearing or speech, or any disorders of the eye, ear, nose or throat?
YES | NO

(k)Cancer, tumours, cysts or growths of any kind?
YES | NO

(l) Any other illness, disorder, operation, physical disability or accident not mentioned above?
YES | NO

10. Have you or your spouse ever been told to have, received any medical advice, counselling or treatment in connection with sexually transmitted disease, AIDS, AIDS Related Complex or any other AIDS related condition?
YES | NO

11. Have you ever had HIV testing done (please state reason and results); or in the last three months had any of the following symptoms for more than one week continuously: fatigue, weight loss, diarrhoea, enlarged nodes or unusual skin lesions?
YES | NO

12. For female applicants only:
(a) Are you now pregnant? If yes, how many months?
YES | NO

(b) Have you ever had any complication(s) in previous pregnancy(ies)? If yes, please provide date and nature of complication.
YES | NO

(c) Have you ever been found to have or are you aware of any breast lumps or disease(s) of the breasts?
YES | NO

(d) Have you ever had any abnormal Pap Smear test or been told by any doctor to have repeat Pap Smear within the next six months?
YES | NO

(e) Have you ever had recurrent/persistent irregular/painful/unusually heavy menstruation?
YES | NO

(f) Have you ever been advised to have a mammogram, biopsy, operation of the breasts, ultrasound of the pelvis, or any other gynaecological investigations?
YES | NO

13. What is the name and address of your regular doctor?

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