0113 265 3759 info@responsemortgages.co.uk

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PROTECTION QUESTIONNAIRE

Step 1 of 5

20%

If you have already spoken to one of our team please let us know their name*
Name*
First Last
Height*
Weight*
Please confirm your waist or dress size*
If you have had any significant weight loss or gain in the last 12 months, please detail
Do you smoke tobacco or use e-cigarettes / vaporisers?*
- Yes
- No
Cigarettes - How many do you smoke a day?
Have your ever smoked tobacco or used e-cigarettes / vaporisers?*
- Yes
- No
If you answered yes above when did you stop?
Average weekly alcohol consumption Monday - Thursday*
Average weekly alcohol consumption Friday - Sunday*
Have you ever exceeded 30 units per week or been advised to reduce / stop alcohol intake on medical grounds?*
- Yes
- No
Please detail why, when and if you are undergoing any treatment*
Have you ever injected non prescription drugs or used recreational drugs?*
- Yes
- No
If YES, please detail what and when
Have you ever been declined or deferred from a protection application?*
- Yes
- No
If YES, please give details
Do you currently have a protection product similar to that you are applying for?*
- Yes
- No
If YES, please give details of Sum/s Assured, Type of Cover and Provider/s
If YES, are you applying for:
- Replacement Cover
- Additional Cover
What percentage of your daily employment involves manual work?*
How many business miles do you travel per year?*
Have you ever lived / travelled or worked abroad for more than 30 consecutive days?*
- Yes
- No
Please confirm which countries you visited, when this was and the duration spent in each.
Do you intend to live/travel/work outside the UK for more than 30 consecutive days?*
- Yes
- No
Please confirm which countries you will be travelling to and the duration you will spend in each one.
Does your work involve heights, working underground, diving or use of dangerous tools or explosives?*
- Yes
- No
If YES, please detail
Do you work in the armed forces or as a member of the armed forces reserves?*
- Yes
- No
Please tick any of the hazardous activities or sports you take part in*
- Aviation
- Horse Riding
- Motorsports
- Climbing
- Diving
- Martial Arts
- Water or Winter Sports
- Motorcycle Riding
- None of the above
You may need to complete a hazardous pursuits questionnaire from the protection provider
If you selected any of the activities above, please detail your involvement

Do you currently have or have had any of the following?
Have you ever tested positive for HIV, hepatitis B or C or awaiting the results of such test?*
- Yes
- No
Please advise date of diagnosis and what treatment you have had/are having.
Cancer, tumour, leukaemia, Hodgkin’s disease, lymphoma, brain or spinal tumour?*
- Yes
- No
Please advise the condition, when diagnosed, treatment, stage of cancer and date all treatment ceased.
Heart disease or disorder, including heart attack, angina, cardiomyopathy, heart valve disorder?*
- Yes
- No
Please advise the name of the condition, when diagnosed, treatment and whether fully recovered.
Stroke, transient attack (TIA), brain haemorrhage, permanent brain damage through accident?*
- Yes
- No
Please advise the name of the condition, when diagnosed, treatment and whether fully recovered.
Multiple sclerosis, Parkinson’s disease, epilepsy, paralysis, Alzheimer's disease, dementia, cerebral palsy?*
- Yes
- No
Please advise the name of the condition, when diagnosed and the treatment you are having/had.
Any other disorder of the central nervous system - brain, spinal cord and nerves, not already mentioned?*
- Yes
- No
Please advise the name of the condition, when diagnosed and the treatment you are having/had.
Any disease or disorder of the arteries, including disease in the leg or of the aorta?*
- Yes
- No
Please advise the name of the condition, when diagnosed, treatment and whether fully recovered.
Diabetes or sugar in the urine?*
- Yes
- No
Please advise the type of diabetes, when diagnosed, treatment and latest HbA1c reading.
Mental illness that has required hospital treatment or referral to a psychiatrist or community health team? (Please note this does NOT refer to psychologists or counsellors)*
- Yes
- No
Please advise name of condition, treatment, type of professional seen and when this was. As much information as you're comfortable giving would be helpful, but if you would prefer to talk this through instead, please let us know here.
Skin disease such as psoriasis or dermatitis?*
- Yes
- No
Please advise the condition, when diagnosed, treatment and whether fully recovered.
In the last 5 years, have you had any of the following?
Have you ever been hospitalised due to COVID, or do you have/have you ever had long COVID? *
- Yes
- No
Please advise dates, treatment and whether fully recovered.
A lump, growth of any kind; or any mole or freckle that has changed size or led to bleeding?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Any blood circulatory problem, chest pain, irregular heartbeat, raised / low blood pressure or raised cholesterol?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered. If you are advising of raised/low blood pressure of cholesterol, please advise your latest reading.
Asthma?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Bronchitis or any other respiratory disorder?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Numbness, loss of feeling or tingling of the face, or temporary loss of muscle power?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Seizure, fits, epilepsy, fainting, dizziness or blackouts?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Disorder of the eyes including blurred or double vision, optic neuritis?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Disorder of the ears, hearing or balance?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Arthritis, rheumatoid arthritis, spine, back, neck or joint disorder, including slipped disk and gout?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Any disorder of the digestive system, liver, stomach, pancreas or bowel, including ulcers, Crohn’s disease?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
A blood disorder or anaemia?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Thyroid disorder?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Kidney, bladder, or any other disease of the genitor-urinary system?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Any sexually transmitted disease or infection?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Any cervical smear needing treatment, investigation or advice, gynaecological disorder or breast problems?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Prostate enlargement or abnormal PSA?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Received any form of medical attention at a hospital?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Any occurrence of depression, stress, nervous breakdown, anxiety or any other mental health issue?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Had any surgical operation?*
- Yes
- No
Please advise the diagnosis, date of diagnosis, treatment had/having and whether you are fully recovered.
Undergone or been advised to have any investigation, x-ray, scan or blood test for any other condition?*
- Yes
- No
Please advise the tests/investigations you are waiting for and the symptoms suffered. Do you have a date for your tests/investigations?
Are you awaiting results of any medical investigation?*
- Yes
- No
Please advise the tests/investigations you had, when these were and when you expect to receive the results.
Are you currently taking any prescribed drugs?*
- Yes
- No
Please advise which drugs, what condition they are treating and the dosage.
Have you been off work for 2 weeks or more for any condition not already mentioned?*
- Yes
- No
Please advise the reason for your absence, length of time you were off and if you are now fully recovered.
Do you intend to seek advice from a medical practitioner for anything not already mentioned or diagnosed?*
- Yes
- No
Please give as much detail as possible, including symptoms suffered.
Considering the types of questions above, is there any other medical disclosure you would like to make?*
- Yes
- No
Please give as much detail as possible

Family History
Before the age of 65, have any of your natural parents or siblings (please note this does NOT include grandparents, uncles or aunts) been diagnosed with or died from any of the following conditions?
Cancer?*
- Yes
- No
Please advise the type of cancer, which relative had it and their age at diagnosis
Heart disease, stroke, diabetes?*
- Yes
- No
Please advise which condition, which relative had it and their age at diagnosis
Multiple sclerosis, Alzheimer's disease?*
- Yes
- No
Please advise which condition, which relative had it and their age at diagnosis
Muscular dystrophy, Parkinson’s disease, motor neurone disease, hemochromatosis?*
- Yes
- No
Please advise which condition, which relative had it and their age at diagnosis
Huntington’s disease, polycystic kidney disease or polyposis of the colon?*
- Yes
- No
Please advise which condition, which relative had it and their age at diagnosis
Any other hereditary disorder?*
Please advise what the condition is, which relatives were/are affected (in this instance please include parents, grandparents, aunts, uncles and half and full siblings) and whether you have been advised to be tested. If you were please advise if you actually had the relevant test/s and the results. As much information as you can give would be helpful.

Doctors Details
Doctor Name*
Surgery Name*
Surgery Address*
Street Address Address Line 2 City Post Code
Telephone*
How many years have you been registered with a UK GP?*

Declarations
Do not sign this declaration unless you are entirely satisfied with it’s content. If you have any questions please consult. I/We agree that this confidential questionnaire and review is a true record of My/Our discussion with the adviser and that this information is true to the best of my/our knowledge. I/We accept that this confidential review relates only to mortgage and protection advice and is not a review for investment advice regulated under the financial services act. I/We confirm that the personal and confidential information provided can be disclosed by the adviser for the purpose of arranging a mortgage and/or protection product on my behalf. I/We have read this completed confidential factfind review form before signing below.
Name
Date
Comments
This field is for validation purposes and should be left unchanged.

TERMS & CONDITIONS

Your initial mortgage consultation is free of charge.
There may be a fee for our mortgage service if you decide to proceed to application, this is typically £495
and we will retain any commission that may be paid by the mortgage lender.

The precise amount will depend on your circumstances and mortgage loan amount and will be
discussed and agreed before you make a mortgage application.

LEGALS

YOUR HOME MAY BE REPOSSESSED IF YOU DO NOT KEEP UP REPAYMENTS ON YOUR MORTGAGE.
Response Mortgage Services Ltd is authorised and regulated by the Financial Conduct Authority and is entered on the Financial Services Register https://register.fca.org.uk/ under reference 435582.

The Financial Conduct Authority does not regulate taxation and trust advice, some forms of buy to let mortgages and some investment mortgage repayment strategies such as shares.

View our Privacy Policy.

Response Mortgage Services Ltd is registered in England No. 5478452.

Registered Office: Suite 6.1 Unit 6 Mortec Park York Road Leeds LS15 4TA
Telephone 0113 265 3759

Where you have a complaint or dispute with us and we are unable to resolve this to your satisfaction, we are obliged to offer you the Financial Ombudsman Service to help resolve this. Please see the following link for further details www.financial-ombudsman.org.uk

This site is for UK residents only

Response Mortgages
Suite 6.1, Unit 6,
Mortec Park,
York Road,
Leeds,
LS15 4TA

0113 265 3759
info@responsemortgages.co.uk

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Life Cover

Making sure your family is protected

Life assurance allows you to make sure your family is protected in the event of your death, during the policy term. You choose the amount of cover you need and the length of time you want to be insured for. Your premiums will never change (unless you change the amount of cover held under the policy or alter the plan), allowing you to budget with confidence.

Why do you need it?

The loss of a spouse or parent can leave dependants with additional issues to cope with other than the emotional. If you are inadequately insured, your dependants may be left with a dramatically reduced household income, which could affect their quality of life. Potentially there may be reduced opportunities for children such as the ability to pay for a university education or difficulties in maintaining mortgage payments on a reduced income. In the event of your death, a lending institution will not write off your debt. Rather, they will continue to pursue the debt through your dependants and could, ultimately, foreclose on the loan meaning the loss of the family home.

What will the State provide?

The main benefits the State may provide are the Widowed Parent’s Allowance and Child Benefit. Depending on whether the widow(er) qualifies for Income Support, the State may or may not help with paying the mortgage interest. The method for calculating which benefits an individual may qualify for is extremely complicated. More information is available at the Department of Work and Pensions website.