Member's Declaration Form

1.1 Scheme name

1.2 Policy number

1.3 Dependants’ Pension – please state the benefit amount

Salary/scheme earnings

2.1 What is your full name?

2.2 What is your gender? Male Female

2.3 What is your date of birth?

2.4 What is your current personal status? Please tick only one box.
Single
Divorced/Dissolved
Married/Civil Partnership
Widow/Surviving Civil Partner

2.5 What is your permanent residential address?

2.6 Contact details

3.1 What is your occupation title?

3.2 Would you describe your occupational duties as: Administrative/office based Light manual Heavy manual

3.3 If you have to drive as part of your occupation, please tell us the percentage of time you spend driving.

3.4 How many hours do you work on average a week?

4.1 During the last 5 years, have you spent more than 90 consecutive days in Africa, Caribbean, Russia, South America, Asia or Ukraine?
Yes No

4.1.1 If ‘Yes’, please give details below

4.2 During the next two years, do you intend to spend more than 30 consecutive days outside the UK or travel for any duration against Foreign Office advice?
Yes No

4.2.1 If ‘Yes’, please give details below

5.1 What is your height?
OR

5.2 What is your weight?
OR

5.3 What is your waist measurement?
OR

5.4 Has your weight changed by more than 2 stone (12.6kg) in the last 12 months?
Yes No

5.4.1 If ‘Yes’, please give details below

5.5 How often do you drink alcohol?
Teetotal 1-2 times a week 3-4 times per week More than 5 times a week

5.6 What is your average weekly consumption of alcohol?

5.7 Have you ever been medically advised to reduce your alcohol consumption?
Yes No

5.7.1 If ‘Yes’, when was that advice given?

5.7.2 How often did you drink alcohol at that time?

5.7.3 What was your alcohol consumption at that time?

5.8 Have you smoked cigarettes or used nicotine replacements including electronic cigarettes, chewing tobacco, cigars or pipe tobacco in the last 12 months?
Yes No

5.8.1 If ‘Yes’, please confirm what is used and the daily amount

5.9 In the last five years have you used any recreational drugs, other than cannabis, for example ecstasy, cocaine or heroin?
Yes No

5.10 Have you ever tested positive for HIV, Hepatitis B or C or are you awaiting the results of such a test?
Yes No

5.10.1 If ‘Yes’, please specify by ticking the boxes opposite
Tested positive for HIV
Tested positive for Hepatitis B
Tested positive for Hepatitis C
Awaiting results for HIV test
Awaiting results for Hepatitis B test
Awaiting results for Hepatitis C test

5.10.2 If you are awaiting the results of a Hepatitis test, please give the reason for the test

5.11 In the last five years have you been exposed to the risk of HIV infection?
Yes No

5.11.1 If ‘Yes’, please tell us if it was because of (you can select more than one box)
Unsafe sex with someone other than a long-term partner
Injecting a non-prescription drug
Blood product or transfusion outside a country stated above
Surgery outside a country stated above

5.12 Do you take part in regular exercise, for example: gym, football, tennis or golf?
Yes No

5.12.1 If ‘Yes’, please give the following details

5.13 Do you take part in, or intend to take part in any hazardous or dangerous activity or pursuit?
Yes No

5.13.1 If ‘Yes’, please give details below

6.1 In the last three years how many days, in total, have you had off work due to sickness or accident?

6.2 Have you ever been absent from work for more than two consecutive weeks due to illness, sickness or accident?
Yes No

6.2.1 If ‘Yes’, please give an explanation below

6.3 Has your health ever affected your ability to perform your occupational duties?
Yes No

6.3.1 If ‘Yes’, please give us an explanation

7.1 What is the name and address of your GP?

7.2 In the last five years, have you been diagnosed as having high blood pressure, been treated for it or ever had a blood pressure reading greater than 150/90?
Yes No

7.2.1 If ‘Yes’, when were you given this diagnosis?

7.2.2 Please provide your last three blood pressure readings

7.3 In the last five years, have you been diagnosed with having high cholesterol, been treated for it or ever had a cholesterol reading greater than 6.5?
Yes No

7.3.1 If ‘Yes’, when were you given this diagnosis?

7.3.2 Please provide your last three cholesterol readings

7.4 Have you ever been diagnosed with Diabetes or having sugar in the urine?
Yes No

7.4.1 If ‘Yes’, when were you given this diagnosis?

7.4.2 Please give your last three glycated haemoglobin (HbA1c) readings

7.5 Have you ever consulted a doctor or any other health care professional due to any form of stress, anxiety, depression or mood disorder?
Yes No

7.6 Have you ever had a panic attack?
Yes No

7.7 Do you or have you ever suffered from Myalgic Encephalomyelitis (ME), Chronic Fatigue Syndrome (CFS) or post-viral fatigue?
Yes No

7.8 Have you ever had a nervous breakdown?
Yes No

7.9 Do you suffer with a bipolar disorder or schizophrenia?
Yes No

7.10 Has your doctor or any other health care professional ever advised you to take medication for stress, anxiety, depression or any other psychological condition?
Yes No

7.11 Have you undergone any other form of treatment for psychological conditions, such as counselling or Cognitive Behavioural Therapy (CBT)?
Yes No

If you’ve answered ‘Yes’ to any of the questions from 7.5 to 7.11, please provide details below

7.12 Do you currently have or have you ever had any of the following?
Yes No

7.12.1 In the last five years, have you had any of the following?
Yes No

7.13 Do you currently, or in the last five years, have you ever had any of the following where no underlying cause has been identified?
Yes No

7.14 Are you currently taking or receiving any treatment that you haven’t already told us about?
Yes No

7.14.1 Are you awaiting the results of any tests or investigations that you haven’t already told us about?
Yes No

7.14.2 In the last 30 days, have you had a new or unexplained continuous cough, fever or high temperature?
Yes No

7.14.2 In the last 30 days, have you tested positive for or been diagnosed with coronavirus/COVID-19?
Yes No

7.14.3 In the last 14 days, have you been self-isolating or been advised you should?
Yes No

Had direct contact with someone who has been diagnosed with, or suspected of having coronavirus?
Yes No

7.15 Have any of your family members, before the age of 65, died from, or suffered from, heart disease, a stroke, diabetes, high blood pressure, kidney disease, cancer, multiple sclerosis, nervous disorder, paralysis or any hereditary disorder?
Yes No

7.16 As part of your occupation or as part of your employment benefits, are you required to attend for regular, annual or biannual medical examinations?
Yes No

7.17 If we need you to attend a medical examination, please tell us where would be most convenient for you to attend

7.18 Have you applied to Legal & General for any other life protection products (either as an individual or through your company)?
Yes No

7.19 Have you ever had an application for life, health assurance or critical illness cover declined, postponed, or accepted with special terms or restrictions, or have you withdrawn an application yourself from this or any other company in the past?
Yes No