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Health Questionnaire (Sole)
1
Notices
2
Personal Details
3
Children / Dependants
4
GP Contact Details
5
Private Medical Information
6
Hobbies & Pastimes
7
Occupation
8
Medical History
9
Additional Medical Details
10
Bank & Trustee Details
The following information will be used by a Life Insurance provider to underwrite your application for life insurance, critical illness and/or income protection insurance. All information is kept private and confidential. 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. 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.
Name
(Required)
Title
Dr.
Miss
Mr.
Mrs.
Ms.
Prof.
Rev.
First
Middle
Last
Date of Birth
(Required)
Day
Month
Year
Current Address
Use the postcode lookup field to find your address, or enter your address manually.
Postcode
Street Address
Address Line 2
City
County
Postcode
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Occupation
Basic Annual Salary
Current Residential Status
Home Owner
Tenant
Living with Parents
Marital Status
Nationality (as on Passport)
Contact Number
Email Address
(Required)
Do you have a will?
Yes
No
Dependants
Please give details of any people that are dependant upon you or your partner.
Dependent (Y/N)
Name
Relationship
Date of Birth
Add
Remove
GP Name & Surgery
Address
Use the postcode lookup field to find GP Surgery address, or enter your address manually.
Postcode
Street Address
Address Line 2
City
County
Postcode
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Have you ever been turned down or been offered special terms by any company?
Yes
No
Have you ever made an income protection or critical illness claim?
(Required)
Yes
No
Private Medical Information
Height
Weight
(If currently pregnant please provide pre-pregnancy weight)
Waist/dress size
Males should specify their waist size, females should specify their dress size
Have you recently lost or gained weight by more than 7kg for any reason other than diet and exercise?
Yes
No
If so, how much? over what period and reason?
If so, how much? over what period and reason?
Have you smoked, used tobacco or nicotine replacement products, such as an E-cigarette in the last 12 months?
Yes
No
If so, what do you smoke and how many a day?
If so, what do you smoke and how many a day?
Have you ever smoked, used tobacco or nicotine replacement products, such as an E-cigarette?
Yes
No
If so, what did you use? When did you start & stop? How many did you smoke per day?
If so, what did you use? When did you start & stop? How many did you smoke per day?
On average how many units of alcohol to you drink per week? 1 pint of beer = 3 units 1 small glass of wine = 1.5 units 1 large glass of wine = 3 units 1 measure spirits = 1 unit
Average Units per week
Have you ever been advised to reduce your drinking on medical grounds?
Yes
No
How many times a week do you exercise?
How many times per week do you exercise?
Have you ever taken non-prescription drugs (e.g. heroin, ecstasy, cocaine)?
Yes
No
Have you lived or worked outside of the UK for more than 3 months in the last 5 years, or do you intend to do so in the next year?
Yes
No
If so, where and for how long?
If so, where and for how long?
Within the last 5 years have you been exposed to the risk of HIV infection?
Yes
No
Have you ever tested positive for HIV, Hepatitis B or C, or are awaiting the results of such a test?
Yes
No
Hobbies & Pastimes
Do you take part in any hazardous sports or pastimes, or do you intend to start? The following are examples, but you should include any activities that are hazardous. If your involvement is, or will be, limited to one occasion, for example a race day, a flying lesson, a trip in a hot air balloon or a team building exercise and you have no intention of pursuing the activity further you need not disclose it.
High Risk/Hazardous Hobbies
Yes
No
Diving
Flying
Motor Sports
Mountaineering/Rock Climbing
Other Hobbies
If you have any other hobbies, please provide details.
Have you been banned from driving or been involved in a road traffic accident that was your fault in the last 5 years, or do you have any motoring prosecutions pending?
Yes
No
Occupation
Does your occupation involved any of the following:
Yes
No
Working at heights over 10 feet (3 meters)?
Working underground
Working underwater
Working offshore (i.e. oil or gas industry)
Working with explosives or firearms
Armed Forces
Professional Sports
Aviation (except as a fare paying passenger)
What percentage of time would you say you spend doing manual work? (By manual work we mean carrying or lifting, moving goods, working with tools or machinery, crawling or kneeling).
0%
25%
50%
75%
100%
Annual total business miles
This is the miles during the working day only e.g. HGV driver etc. This does not include ordinary commuting from home to a permanent workplace.
What percentage of your working day would you say you spend driving?
Exclude your commute.
0%
25%
50%
75%
100%
Absences from Work
How many times have you been off work because of illness, an accident for more than 2 weeks, in the last 5 years?
None
Once
Twice
Three times
Four or more times
Second Job
Do you currently have a second job?
Yes
No
Second Job Title
Percentage of day spent manual working (second job)
0%
25%
50%
75%
100%
Annual total business miles
This is the miles during the working day only e.g. HGV driver etc. This does not include ordinary commuting from home to a permanent workplace.
Percentage of day spent driving (second job)
0%
25%
50%
75%
100%
Medical History
If you answer yes to any of the questions in this section, please provide details in the further information box at end of form.
Medical History
Have you had or do you currently have any of the following illnesses?
Yes
No
Cancer, Leukaemia, Hodgkin’s disease, Lymphoma, brain or spinal tumour
Heart Disease (including heart attack, angina, heart defects from birth or heart surgery)
Stroke, brain haemorrhage or brain injury
Multiple Sclerosis, optic or retro bulbar neuritis, Parkinson’s disease, paralysis, epilepsy, Alzheimer’s disease, dementia or cerebral palsy
Any other disorder of the arteries (incl disease in the legs or of the aorta)?
Diabetes or sugar in the urine
Mental illness that has required treatment or referral to a psychiatrist
Recent Health
Have you had any of the following within the past 5 years?
Yes
No
A mole or freckle that has bled, caused pain or changed in appearance or any lump or growth?
Chest pain, irregular heartbeat, raised blood pressure or raised cholesterol?
Asthma, bronchitis or any other respiratory disorder?
Numbness, loss of feeling or tingling of the limbs or face, loss of balance or co-ordination?
Seizures, fits, fainting or blackouts?
Any disorder of the eyes or ears, including blurred or double vision, or impaired hearing (You can ignore sight problems corrected by glasses or contact lenses)
Arthritis, back pain, sciatica, neck, knee or wrist pain or any other joint, bone or muscle disorder (including RSI)
Any disorder of the digestive system, liver, stomach, pancreas or bowel (including ulcers, hepatitis, colitis, or Crohn’s disease)
Any blood disorder
Any thyroid disorder
Any disorder of the kidney, bladder or genitor urinary system (including urinary tract infections and blood or protein in the urine)
Treatment or a positive test for any disease which was transmitted sexually
Any gynaecological disorders? Abnormal smear test, etc.
Depression, anxiety, stress, fatigue or nervous breakdown
Experienced any of the following symptoms: a cough, breathing difficulties, a high temperature or fever, or a loss or change to your sense of taste or smell
Been diagnosed with Coronavirus
In the last three months have you had any new symptoms of fatigue, persistent tiredness, muscle aches or joint pains even if you have not consulted a doctor?
Health Consultations
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 checkups where the results are normal.
Have you had any of the following within the past 5 years?
Have you had any of the following within the past 5 years?
Yes
No
Other than consultations to do with the above points, have you had a medical consultation in the last 12 months (e.g. Doctor, Consultant, Psychiatrist, Hospital, Clinic Osteopath)
Have you ever had (or been advised to have) any medical investigation, scan, test or attended hospital in the last 5 years?
Are you awaiting any medical consultation, check up, investigation, scans or tests?
Have you been prescribed any drugs or been given any other treatment in the last 12 months?
Have you ever undergone any surgical procedure outside the European Union or been a recipient of blood products outside the European Union?
Family Health
Have either of your natural parents, brothers or sisters suffered or died before the age of 65 from any of the following?
Yes
No
Cancer
Heart Disease
Stroke
Diabetes
Multiple Sclerosis
Huntington’s Disease
Polycystic Kidney disease
Polyposis of the colon
Any other hereditary disorder
Family Health History
Family Member
Condition
Age Diagnosed
Add
Remove
Additional Details
If you have answered yes to any questions, please provide further information on dates / medication /outcomes
As part of our service we will arrange for your new policies to be placed in Trust at no additional cost.
Placing your policy in trust ensures that the funds from your life insurance policy are used exactly as you intend. If you do not have a trust, then the money could be used to pay off outstanding debts, rather than going to your surviving partner and/or dependents as you wish.
To do this, we require you to name at least two people that you wish to nominate as your trustees and provide me with their full name, address, date of birth and contact number.
These should be people you would trust to look after your family, should something happen to both of you. You will also be a Trustee on the policies.
Name (Trustee 1)
First
Last
Date of Birth (Trustee 1)
day
month
year
Contact Number
Address (Trustee 1)
Postcode
Street Address
Address Line 2
City
County
Postcode
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Name (Trustee 2)
First
Last
Date of Birth (Trustee 2)
day
month
year
Contact Number
Address (Trustee 2)
Postcode
Street Address
Address Line 2
City
County
Postcode
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Name (Trustee 3)
First
Last
Date of Birth (Trustee 3)
day
month
year
Contact Number
Address (Trustee 3)
Postcode
Street Address
Address Line 2
City
County
Postcode
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