Stomach & Gastro-Intestinal Issues Life Insurance Questionnaire

Stomach & Gastro-Intestinal Disorders Questionnaire

If you have a stomach or gastro-intestinal disorder, getting a real quote for insurance is a little trickier, which is why I need more information from you. The more information you give me, the more accurate a quote I can give you. Sure, it’ll take you a few extra minutes but it’ll get us one step closer to securing your family’s future.
1. What is the name of the condition you suffer from?*

Barrett’s Oesophagus Indigestion Reflux Coeliac Disease Irritable Bowel Syndrome Spastic Colon Heartburn Oesophagitis Ulcer Other (please specify)
2. When was the condition diagnosed or when did you first experience symptoms? Date*
3. Was there any question of cancer or malignancy? If so, please complete Cysts, Lumps, Growths Questionnaire.*
- Yes
- No
4. How would you describe the frequency of your symptoms?*

Continuous Frequent Occasional Once only
5. Have you ever had any tests or investigations carried out in connection with this condition? (e.g. blood tests, endoscopy, ultrasound, colonoscopy, gastroscopy, barium meal or enema, biopsy or other). If yes, please give details*
6. Do you currently take any medication for this condition? If yes, give details*
7. Have you ever had time off work or been treated as an inpatient because of your condition?*
8. Have you ever had or been advised to have, or are you awaiting any form of surgery?*
9. When and with whom was your last consultation?*
10. Please provide any additional information that you feel is important:*
11. What's your date of birth?*
12. Which of the following insurers have you tried already?
- Aviva
- Irish Life
- Laya
- New Ireland
- Royal London
- Zurich/VHI
- None of the above
First Name*
Email*
Phone number (if you'd like a callback)
Thanks for completing the form, now please hit the send button below so we can review and come back to you with an accurate quote.

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Stomach & Gastro-Intestinal Issues Life Insurance Questionnaire

Stomach & Gastro-Intestinal Disorders Questionnaire

Thanks for completing the form, now please hit the send button below so we can review and come back to you with an accurate quote.

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