Shireen Kort
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Home
About
Insurance Types
Contact
Get An Insurance Quote
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Step
1
of 3
Gender
Male
Female
Other
Marital Status
Married
Single
Civil Partnership
Common-Law
Cohabiting
Divorced
Separated
Widowed
Next
What type of Insurance do you want?
*
Life Insurance
Health Insurance
Do you already have an Insurance
Yes
No
Next
Cover Amount for Life Insurance
Policy Duration for Life Insurance
In the last 5 years have you had any of these?
*
Depression
Anxiety
Stress
Any Other Mental Health Issue
None of these
Have you ever had any of these?
*
Eating Disorder
Bipolar Disorder
Manic Depression
Schizophrenia
Psychosis
None of these
In the last 5 years have you had any of these?
*
Raised blood pressure, cholesterol, or chest pain
Diabetes or raised blood sugar
Anemia, blood clot, or anything else affecting your blood
A growth, lump, or cyst
Asthma, sleep apnoea, or anything else affecting your lungs or breathing
Kidney stones, urinary infection or anything else affecting your kidneys, prostate, bladder or urine
Back pain, sciatica, whiplash or anything else affecting your back or neck
Impaired, blurred or double vision, optic neuritis or anything else affecting your eyes
None of these
Cover Amount for Health Insurance
*
Policy Duration for Health Insurance
*
In the last 5 years, have you had any of these?
*
High blood pressure
High cholesterol
Diabetes or raised blood sugar
Asthma, COPD, or other lung/breathing issues
Sleep apnea
Chest pain
Anemia, blood clots, or other blood disorders
Back pain, sciatica, or spinal issues
Kidney stones or urinary problems
A growth, lump, or cyst
Blurred/double vision or eye disorders
None of these
Have you ever been diagnosed with any of these mental health conditions?
*
Bipolar disorder
Manic depression
Psychosis
Schizophrenia
Eating disorder
None of these
Current Medications
How often do you visit a doctor or specialist per year?
*
Rarely (1–2 times/year)
Occasionally (3–5 times/year)
Frequently (6+ times/year)
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