Clients Declaration Form

Note: This form is to be completed by the client in their own hand writing and all questions to be answered in full. Discuss with your advisor if you do not understand any questions or consult your GP if you are unsure of any answers to any medical conditions.

Please indicate by writing YES or NO if you are currently suffering from, experiencing symptoms of or being treated for, or if you have ever suffered from, had symptoms of or had treatment for any of the following.

Please initial at bottom to confirm you have read and understood this question

BEFORE YOU SIGN THIS PLEASE READ AND INITIAL THE NEXT PAGE WHICH PROVIDES INFORMATION ON YOUR DUTY OF DISCLOSURE

DUTY OF DISCLOSURE

The DUTY OF DISCLOSURE means that you have a duty to disclose every information that you know ( or could reasonably beexpected to know ) in relation to all questions asked especially your medical history on the client declaration form. Our recommendations and the contract of life insurance will be based on the information you provide and failure to provide correct information may lead to your claim being declined and policy cancelled.