Anything-Direct Insurance Services 
Charter House
43 St Leonards Road
Bexhill on Sea
East Sussex 
TN40 1JE

Fax: 01424 731781

ANYTHING-DIRECT UNIT LIFE ASSURANCE PROPOSAL FORM

All material facts must be disclosed as failure to do so would nullify any policy issued. You must inform the Underwriter if there is any change in your health or you suffer any illness or injury between the time you complete this form and when you receive your policy.

1. Within the last 5 years have you had any illness, injury, condition or incident that has required 
   you to attend any specialist, hospital or clinic for any consultation, treatment, investigations 
   or test or for which investigation or treatment is proposed?                                                                  YES / NO
   
2. Are you currently suffering from any disability or illness or receiving any form of medication
   or treatment?                                                                                                                                                   YES / NO
   
3. What are your height and weight     Height: _________________     Weight: _________________
   
4. Have you ever been tested for HIV/AIDS or Hepatitis B or C, or are you awaiting the result of 
   such a test?                                                                                                                                                      YES / NO
   
5. Has any application for insurance on your life ever been declined, postponed, accepted at an
    increased premium or with an exclusion imposed, or have you ever withdrawn an application?      YES / NO
   
6. Have you smoked any form of tobacco in the last twelve months?                                                        YES / NO

Summary.  Before Underwriters can apply for a medical report from your doctor, they need your consent.  You should know that you have cerain rights under the Act.  The main points are as follows:  (a) You can withhold your consent.  (b) You can see the report before it is sent to the Underwriters Senior Medical Adviser, or during the six months after that.  (c) You can ask the doctor if he will amend any part of the report which you consider to be incorrect or misleading.  If the doctor is not in agreement you may append your comments.  (d) The doctor can withhold from you the report or part of it, if he thinks that you would be harmed by seeing it.

If you do not say you wish to see the report, the Underwriters do not have to notify you if they apply for one.  However, if before such a report is sent to them, you write to the doctor saying that you wish to see it, you will have 21 days to contact the doctor to make arrangements to see the report.

Whether or not you say you wish to see the report before it is sent to the Underwriters, the doctor must let you see a copy for up to six months after it is supplied, if you ask.  If you ask the doctor for a copy of the report he can charge you a reasonable fee to cover his costs.

Once you have seen a report before it is sent to the Underwriters the doctor cannot submit until he has your consent.  You can write to the doctor asking him to amend any part of the report you consider to be incorrect or misleading and can attach to the report a statement of you views on any part where you and your doctor are not in agreement and the doctor is not prepared to alter.

The doctor is not obliged to let you see any part of the report if in his opinion, that would be likely to cause serious harm to your physical or mental health or that of others, or would indicate the doctors intentions towards you, or if a disclosure would be likely to reveal information about, or the identity of, another person that has supplied information about you, unless that person has consented or the information relates to, or has been supplied by, a health professional involved in caring for you.  In such cases, the doctor must notify you and you will be limited in seeing any remaining part of the report which is affected, he must not send it to the Underwriters unless you give consent.

I declare that all statements herein are true to the best of my knowledge and belief.  I am aware that the Underwriters will rely on the statements made herein and the statements made by me to any medical examiner appointed by the Underwriters when making the contract.  I consent to the Underwriters seeking medical information from any doctor who at any time has attended me concerning anything which affects my physical and mental health or seeking information from any insurance office to which a proposal has been made for insurance on my life and I authorise the giving of such information.