Medical Questionnaire


    Which protection product would you like advice on?

    Person 1


    Do you know how much cover you need and the amount of years you need the policy for?

    You do not need to disclose non-hazardous team sports such as football, rugby, or hurling.

    Occupation Questionairre






    How much did you earn (pre-tax) over the last 12 months? Including overtime, commission and bonuses but not including investment income or income from other sources.

    Business KM's per year, excl. commuting.

    Health Questionairre


    Have you smoked or used tobacco products (including vapes) within the last 12 months?
    How many, if applicable, of the following would you general use per day?


    Including roll-ups

    Roughly how many grams per day?

    If pregnant, what was your weight before the pregnancy?

    You do not need to tell us about contraception, fertility, dental treatment or reviews purely in relation to pregnancy.

    You do not need to tell us about contraception, fertility, dental treatment or reviews purely in relation to pregnancy.

    For example: Bleeding from the bowels or change in bowel habit, persistent cough, weight loss, onset of fits or seizures, dizziness, blackouts or fainting.
    Heart Attack or Angina, Cancer (including Leukaemia or Lymphoma), Multiple Sclerosis, Muscular Dystrophy, Motor Neurone Disease, Cardiomyopathy, Polycystic Kidney Disease, Familial Colon Polyps, Stroke, Diabetes, Huntington’s Disease, Alzheimer’s Disease, Parkinson’s Disease, Haemochromatosis.

    Covid 19

    Within the last 30 days...

    Person 2


    Do you know how much cover you need and the amount of years you need the policy for?

    You do not need to disclose non-hazardous team sports such as football, rugby, or hurling.

    Occupation Questionairre






    How much did you earn (pre-tax) over the last 12 months? Including overtime, commission and bonuses but not including investment income or income from other sources.

    Business KM's per year, excl. commuting.

    Health Questionairre


    Have you smoked or used tobacco products (including vapes) within the last 12 months?
    How many, if applicable, of the following would you general use per day?


    Including roll-ups

    Roughly how many grams per day?

    If pregnant, what was your weight before the pregnancy?

    You do not need to tell us about contraception, fertility, dental treatment or reviews purely in relation to pregnancy.

    You do not need to tell us about contraception, fertility, dental treatment or reviews purely in relation to pregnancy.

    For example: Bleeding from the bowels or change in bowel habit, persistent cough, weight loss, onset of fits or seizures, dizziness, blackouts or fainting.
    Heart Attack or Angina, Cancer (including Leukaemia or Lymphoma), Multiple Sclerosis, Muscular Dystrophy, Motor Neurone Disease, Cardiomyopathy, Polycystic Kidney Disease, Familial Colon Polyps, Stroke, Diabetes, Huntington’s Disease, Alzheimer’s Disease, Parkinson’s Disease, Haemochromatosis.

    Covid 19

    Within the last 30 days...

    Form Submission


    Do you consent to Inverdea contacting you?

    You confirm that you have read and agree to our Terms of Business.
    Terms of Business need to be accepted before you can submit your application

    This site is protected by reCAPTCHA and Google Privacy Policy and Terms of Service apply.
    © 2021  Inverdea Financial Services
    Inverdea Financial Services Ltd. is regulated by the Central Bank of Ireland
    Click here for information on charges
    Proudly Designed by Wikid
    chevron-down linkedin facebook pinterest youtube rss twitter instagram facebook-blank rss-blank linkedin-blank pinterest youtube twitter instagram