Insurance Fact Find -

Lets Get To Know You

Before we get started, we’d love to get to know you a bit more. The form below asks for some key details about your finances and property plans so we can give you the best possible advice. It helps us understand your situation and come prepared to make your future appointments as smooth and helpful as possible. Don’t worry, everything you share is treated with care and kept completely confidential.

Insurance Fact Find

Full Name *

Date Of Birth *

Select Date Of Birth

Marital Status

Current Address *

Address Line 1

Address Line 2

City

County

Postcode

Country

Nationality *

Phone *

Email *

Do You Smoke? *

Employment & Income

Employment Status *

Employed
Self-employed
Retired
Other

Other

If other tell us more about your situation

Employer Name *

Job Title *

Gross Annual Income

Additional Income

Dependants

Do You have any Dependants

Number of Dependants

Provide Details: Name(s)Age, Relationship

Existing Insurance Policies

Do You Have Any Existing Insurance Policies (Tick all that apply)

Life Insurance
Critical Illness
Income Protection
Private Medical Insurance
Employer Benefits (e.g. Death in Service)

Provide Details (If applicable)

Cover Type, Provider, Monthly Premium, Amount Insured, Term Remaining, Start & End Date

Mortgage & Financial Commitments

Do you currently have a mortgage?

Outstanding Mortgage Amount: *

Enter 0 if not applicable

Monthly Mortgage *

Enter 0 if not applicable

Remaining Term

Other debts or financial commitments *

Health and Health History

How tall are you?

How much do you weigh?

In the last 5 years have you had any of these? (Select all that apply)

Depression
Anxiety
Stress
Any other mental health issue
None of these

Have you ever had any of these? (Select all that apply)

Eating disorder
Bipolar disorder or Manic depression
Schizophrenia
Psychosis
Personality disorder
None of these

Have you ever: (Select all that apply)

Tried to take your own life
Had thoughts about taking your own life
Neither of these

Have you ever had any of these? (Select all that apply)

Cancer, cancer-in-situ, leukaemia, Hodgkin's disease or any other tumour
Heart attack, irregular heart beat, cardiomyopathy, valve disorder or any other heart condition or heart surgery
A stroke, TIA, brain haemorrhage or damage or surgery to your brain
No

If you have any of the above please enter details

In the last 5 years have you had any of these? (Select all that apply)

Raised blood pressure, cholesterol or chest pain
Diabetes, borderline diabetes, pre-diabetes, raised blood sugar or sugar in the urine
Anaemia, blood clot or anything else affecting your blood
A growth, lump or cyst
No

If you've had any of the above in the last 5 years please enter details

Have any of these applied to you in the last 3 years? You don't need to include things you've already told us about. (Select all that apply)

I've taken or been prescribed treatment for 4 weeks or more
I've been asked to attend a follow-up or regular reviews with a GP, hospital or clinic
I've been advised to see a specialist or to have any tests, scans, investigations or counselling
No

If you've had any of the above in the last 3 years please enter details

Which of the following describe you?

If you used to smoke or vape when did you stop?

Have your birth parents, brothers, or sisters had any of these before they were 65? (Select all that apply)

Muscular dystrophy, Huntington's disease or motor neurone disease
Multiple sclerosis, Parkinson's disease or Alzheimer's disease
Heart attack, angina or stroke
Cardiomyopathy
Diabetes
Bowel cancer or bowel polyps
Any other cancer
Polycystic kidney disease
I don't know
No

Have you ever: (Select all that apply)

Intentionally harmed yourself
Had thoughts about harming yourself
Neither of these

Have you ever had any of these? (Select all that apply)

Multiple sclerosis, epilepsy, Parkinson's or any other disorder of the brain or nervous system
A positive test for HIV
Hepatitis B or C
A test for HIV or hepatitis B or C that I’m currently waiting for the results of
No

If you have any of the above please enter details

Asthma, sleep apnoea or anything else affecting your lungs or breathing (Select all that apply)

Asthma, sleep apnoea or anything else affecting your lungs or breathing
Long COVID (symptoms of Coronavirus that have lasted longer than 12 weeks)
Crohn's, colitis, IBS, or anything else affecting your stomach, bowel or digestive system
Kidney stones, urinary infection or anything else affecting your kidneys, prostate, bladder or urine
Anything affecting your liver or pancreas
No

If you've had any of the above in the last 5 years please enter details

Have you had any of these in the last 3 months, even if you haven't seen a doctor? You don't need to include things you've already told us about. (Select all that apply)

Any lump, growth or hardening affecting either testicle
Bleeding from the bowel or a change in bowel habit
A fit or seizure
A cough lasting more than 3 weeks
A mole or skin blemish which has changed in appearance
No

Lifestyle

Do you drink?

Number of beer, lager or cider you drink per week?

Glasses of wine you drink per week?

Measures of spirits you drink per week?

Other alcoholic drinks you drink per week?

Have you taken any drugs

When did you stop? (If Yes)

Are you still taking/using this other/unknown drug either on a regular or occasional basis?

When did you last use this other/unknown drug? (If Yes)

Have you ever injected non-prescribed drugs?

When did you last inject any non-prescribed drug? (If Yes)

Have any of these applied to you?

I've been banned from driving or convicted of dangerous or careless driving in the last 5 years
I ride a motorbike, scooter or moped on the road
No

Have you lived or worked outside of the UK or European Union in the last 2 years, or do you have any plans to do so in the next year?

Do you have existing Life insurance or are you applying for any other Life insurance?

Have any of these applied to you? (Select All That Apply)

I've been advised by a medical professional to cut down or stop drinking alcohol
I've attended, or been referred, for alcohol or drug specialist support such as Alcoholics or Narcotics Anonymous
I've used recreational drugs in the last 10 years
No

Did you attend, or was your referral for, alcohol or drug support? (Select All That Apply)

Alcohol support
Drug support

Have you taken any of these drugs? (Select All That Apply)

Amphetamines (e.g. ecstasy, speed, uppers)
Anabolic steroids or other performance enhancing drugs
Barbiturates
Cannabis
Cocaine
Hallucinogens (e.g. acid, LSD, magic mushrooms)
Opiates (e.g. heroin, methadone, morphine)
Sedatives (e.g. downers, tranquillisers)
Solvents (e.g. aerosol abuse, glue abuse)
Other or unknown

Provide Details (If any of the above apply)

Are you involved in any of these? (Select All That Apply)

Armed forces
Armed forces reserves
Martial arts or combat sports
Motor car or motorcycle sport
Mountaineering or rock climbing
Private flying, gliding or parachuting
Sailing at sea
Powerboat racing
Scuba diving
No

Provide Details (If any of the above apply)

Protection Goals

What are your main protection priorities?

Mortgage cover
Family income
Legacy planning

What are your main protection priorities?

Mortgage cover
Protecting my family if I pass away
Replacing lost income if I can't work
Ensuring financial support for my children
Other

If Other

How much monthly budget would you be comfortable allocating to protection policies? *

Any health or lifestyle factors we should be aware of?

Notes/ Comments

Communication

Communication
Telephone
Social Media
SMS/Text

Zelus Mortgage and Finance may wish to contact you periodically to let you know about products or services that may be of interest to you. By ticking the box/s above you provide your express consent for Zelus Mortgage and finance to contact you with marketing material via the relevant channel/s.

Declarations & Consents *

I/We confirm that the information provided is true and complete
I/We give consent for credit checks and document verification as needed.
I/We understand that Zelus Mortgage and Finance can only advise me/us based on the information that I/We have disclosed.
I/We provide express consent for Zelus Mortgage and Finance to contact me regarding my mortgage arrangements

Signature *

Date *

Message