Medical Form | Michael Chandler Mortgages

Medical Form

It's very important you answer every question on the application truthfully and accurately to ensure all valid claims are paid to protect you and your dependents. If you don't, it could mean a claim may not be paid and your policy may be cancelled. Your provider won't always write to your doctor to confirm your answers.

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MC Medical Form

We will not share this information with anyone without your permission.

If there are any questions you would prefer to answer direct to your provider please mark 'Private' beside the specific question.

We will provide the necessary contact details to allow you to complete your application.

Elderly Women Talking To Doctor

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If you would like to contact us call 02890 450 550 (option 2)

Contact details

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Private Medical Information

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(Exercise is defined as any activity that causes an increase in body temperature, breathing and/or heart rate. Exercise can include sports like running or cycling or a lifestyle activity like a brisk walk or gardening.)
(This includes the use of a motorcycle by a pillion passenger)
(one unit = a single measure of spirits, 1 glass of wine, or a half-pint of beer)
HIV can be caught through unsafe sex, intravenous drug abuse, blood transfusions undertaken outside the European Union or surgery taken outside the European Union). If the result is negative, the fact of having an HIV test will not in itself have any effect on your application terms for insurance.

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(Exercise is defined as any activity that causes an increase in body temperature, breathing and/or heart rate. Exercise can include sports like running or cycling or a lifestyle activity like a brisk walk or gardening.)
(This includes the use of a motorcycle by a pillion passenger)
(one unit = a single measure of spirits, 1 glass of wine, or a half-pint of beer)
HIV can be caught through unsafe sex, intravenous drug abuse, blood transfusions undertaken outside the European Union or surgery taken outside the European Union). If the result is negative, the fact of having an HIV test will not in itself have any effect on your application terms for insurance.

Hobbies & Past Times

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Occupational Details

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Does your occupation involve any of the following

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(By manual work we mean carrying or lifting, moving goods, working with tools or machinery, crawling or kneeling)

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(By manual work we mean carrying or lifting, moving goods, working with tools or machinery, crawling or kneeling)

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If you answered yes to the above question please complete the following

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Do you currently have, or have had, any of the following

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Recent HealthIn the last 5 years have you had any of the following

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You do not need to give details of occasional consultations with your GP for just colds or flu, or for consultations for oral contraceptive pills, smear tests, well woman/man check-ups where the results are normal.

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You do not need to give details of occasional consultations with your GP for just colds or flu, or for consultations for oral contraceptive pills, smear tests, well woman/man check-ups where the results are normal.

If either applicant answered 'yes' to any of the above questions, please answer the below questions (relating to each condition, if applicable) in the text box provided.


Please give as much detail as possible.

  • Name of Condition
  • Date First Occurred
  • Date Last Occurred
  • Were you prescribed treatment or medication? (Yes/No). If so, please give details
  • Have your fully recovered?
  • When was your most recent time off work relating to above condition?
  • Are you receiving treatment for this condition?
  • Will you have to have any operation / treatment in the future related to this condition? If so, can you specify the dates this is to occur?

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Family Health

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What age are your parents?

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What age are your parents?

Have either of your natural parents, brothers or sisters been diagnosed with or died before the age of 65 from any of the following?

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If you answered yes to any of the questions in this section, please provide details below Please list Family Member (Father, Mother, etc.), their condition and age they were diagnosed

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Direct Debit Details

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Additional InformationList any additional information that could help with your application

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Covid-19


In the last 30 days have you:

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In the last 14 days have you:

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(Please answer no if you are following general self-distancing advice to avoid spread of the virus or working from home due to workplace advice only)

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(Please answer no if you are following general self-distancing advice to avoid spread of the virus or working from home due to workplace advice only)

Data Protection Declaration

Michael Chandler Insurance Choices and First Complete Ltd will process all information in accordance with the Data Protection Act 1998 and it will be treated as private and confidential now and in the future. The only exceptions to this will be when the law requires us to disclose information or, with your consent, where disclosure is necessary when arranging or servicing your mortgage or protection contracts.

To fulfil our regulatory obligations, we will retain copies of your records for no longer than is necessary or for the duration of any contract you may enter into. You have the right to inspect these records at any time.


Our Future Relationship

Our ongoing business relationship with you is important and we would like to be able to contact you by telephone, post or email from time to time to review your mortgage and associated protection product arrangements and introduce other services that may be of interest to you from ourselves or our associated companies.