Lifestyle Questions - International Private Medical Insurance

Names*
Main Applicant/ Policyholder Spouse/Partner Child Dependant 1 Child Dependant 2 Child Dependant 3 Child Dependant 4
Height: (Please specify cm or inches)*
Main Applicant/ Policyholder Spouse/Partner Child Dependant 1 Child Dependant 2 Child Dependant 3 Child Dependant 4
Weight: (Please specify kg or pounds)*
Main Applicant/ Policyholder Spouse/Partner Child Dependant 1 Child Dependant 2 Child Dependant 3 Child Dependant 4
Have you smoked any tobacco products in the last year? If yes, please specify how much you smoke per week:*
Main Applicant/ Policyholder Spouse/Partner Child Dependant 1 Child Dependant 2 Child Dependant 3 Child Dependant 4
Do you consume alcohol? If yes, please specify how many units you consume per week? e.g. 1 pint of beer = 2.5 units, 1 bottle wine = 10 units*
Main Applicant/ Policyholder Spouse/Partner Child Dependant 1 Child Dependant 2 Child Dependant 3 Child Dependant 4
Approximately how many hours do you exercise per week?*
Main Applicant/ Policyholder Spouse/Partner Child Dependant 1 Child Dependant 2 Child Dependant 3 Child Dependant 4
Number of days absent from work due to ill health in the last year?*
Main Applicant/ Policyholder Spouse/Partner Child Dependant 1 Child Dependant 2 Child Dependant 3 Child Dependant 4
Policy ID*
Name of person completing form*
Date*
Email*
Any additional information/comments
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By submitting this form, you are providing consent to process the data that you have supplied in this form to enable us to deal with your Expacare policy. I understand that I am completing this form on behalf of a number of persons to be covered and I will make them aware of the information that I have provided. I declare that to the best of my knowledge and belief, the information given on this form and any additional information supplied is true and complete and that the information completed is full and accurate. I understand and accept that in the event of this form being fraudulent in whole as or in part, the policy may be invalidated and I will be liable for prosecution. I understand that if I provide inaccurate or incomplete information, my claim may be rejected.

Main Applicant/ Policyholder	Spouse/Partner	Child Dependant 1	Child Dependant 2	Child Dependant 3	Child Dependant 4