Is your occupation 100% administration/supervisory/managerial?*

Do you work at heights above 50 feet?*

What nationality are you?*

What is your height?*

What is your Weight?*

A. Heart attack, angina, heart bypass surgery, heart valve disorder, heart murmur, angioplasty, heart related chest pain or any other heart disease or disorder?*

B.Problems with the aorta, poor circulation in the legs or problems with the arteries excluding cholesterol?*

C.Cancer, malignant tumour, leukaemia, Hodgkin’s disease, Non Hodgkin’s disease, Lymphoma or any brain or spinal tumour?*

D.Schizophrenia, bipolar affective disorder/manic depression, psychosis, paranoia or mania?*

E.Stroke, TIA or mini stroke, brain haemorrhage, brain or spinal cord injury, coma or amnesia?*

H.Diabetes, sugar in the urine, raised blood sugar, low blood sugar or glucose intolerance?*

I.Hepatitis. Cirrhosis of liver. other liver disorders, pancreatitis, ulcerative colitis, Crohn’s disease or removal of part or all of the bowel/colon?*

J.Have you ever had treatment or counselling for alcohol excess or misuse or have you ever been advised by a medical practitioner to cease or reduce your alcohol consumption?*

K.Have you ever used any recreational drugs such as cannabis, cocaine, heroin, ecstasy, amphetamines, anabolic steroids or non-prescription sedatives?*

L.Have you ever tested positive for HIV or are you awaiting the result of a HIV test?*

M.Within the last five years have you tested positive for, or been treated for any disease which was transmitted sexually?*

a. Asthma, bronchitis, emphysema or any other lung or breathing disorder? *

b.High blood pressure, raised cholesterol or low blood pressure?*

c.Depression, stress, anxiety, eating disorders, chronic fatigue syndrome or other nervous or mental disorder?*

d.Epilepsy, seizure, fit, fainting, dizziness, blackouts, severe headaches, migraines, concussion, meningitis or encephalitis? *

e.Back and neck disorders including disc problems, sciatica, whiplash, diseases of the spine, back and neck pain or trapped nerves? *

e.Back and neck disorders including disc problems, sciatica, whiplash, diseases of the spine, back and neck pain or trapped nerves? *

g.Disorder of the digestive system or stomach, including reflux, ulcers, hernia, oesophagitis, or Coeliac disease?*

h.Thyroid problems, goitre or glandular fever?*

i.Disorder of the eyes that is not corrected by spectacles or contact lenses including: impaired vision, blindness, cataract or glaucoma?*

j.Disorder of the ears, nose or throat including: hearing impairment/ deafness or vertigo?*

k.Anaemia, blood clotting disorders, haemophilia, haemochromatosis, thalassaemia or other blood disorders? *

l.Kidney stone(s), disease or surgery, prostate problems, testicular problems or abnormal urine test results? (male only)*

-Kidney stone(s), disease or surgery or abnormal urine test results? (female only) *

m.Abnormal smear teat results, menstrual disorders, hysterectomy, endometriosis, fibroids, ovarian cysts or mammogram which has required further investigation?*

n.Have you had any medical investigations, scans or tests within the 5 last years?*

o.Are you receiving or awaiting ongoing medical treatment, referral, medical investigation, test results, surgical procedure or intending to seek medical advice or treatment.*

a.Cancer of the breast, ovaries, colon, bowel, rectum, stomach, polyposis of the colon or any other form of cancer*

b.Heart attack, angina, heart by-pass, angioplasty, heart failure, cardiomyopathy, stroke, diabetes, haemochromatosis, high blood pressure or raised cholesterol?*

c.Multiple sclerosis, Huntington’s disease. Polycystic kidney disease, motor neurone disease, muscular dystrophy, Parkinson’s or Alzheimer’s disease?*

d. Apart from the conditions listed above. Have 2 or more of any of your biological parents, brothers or sisters had the same condition before the age of 65?, motor neurone disease, muscular dystrophy, Parkinson’s or Alzheimer’s disease?*

e. Other than a genetic test have you undergone or been advised to have any specific tests or investigations as a result of a condition one of your biological parents, brothers or sisters had?*

a.In the last 10 years, have you spent more than 6 months outside of Ireland, the EU, North America, Japan, Singapore, Hong Kong, New Zealand or Australia?*

b.In the next 12 months, do you intend to travel or reside for more than 30 days outside of Ireland, the EU, North America, Japan, Singapore, Hong Kong, New Zealand or Australia?*

c.Do you take part in or intend to take part in any hazardous leisure activities or sports such as scuba diving, motor sports, aviation, water sports, horse riding, martial arts, mountaineering, caving or winter/ice sports?*

Have you ever had an application on your life declined, postponed, accepted at an increased premium or with an exclusion imposedfor any death, specified or critical illness or disability benefit? *

Name*

I have read and understand the replies to all the questions in this application and declare that all statements herein are true to the best of my knowledge.*