Health declaration debt balance insurance

Your name

Your first name

 
Your height?

Your weight?

Are you a smoker?

Make your choiceYesNoStopped for more than 12 months

I declare that I have never been medically declined for underwriting life insurance or guaranteed income insurance and have no similar application pending with any other insurance company.

Make your choiceYesNo

I expressly declare to be in good health and to the best of my knowledge NOT to have suffered or to have suffered during the last 10 years from any serious illness, infirmity or condition*.

*Serious includes, the following diseases, defects or disorders: (not suffering from)
- disorders of the nervous system or neuromuscular diseases (cerebral haemorrhage, Huntington's disease, CVA, MS , ALS, epilepsy)
- cardiovascular diseases (heart disease, infarction, thrombosis)
- neo-proliferative disorders and blood diseases (cancer, tumour, leukaemia, haemophilia)
- infectious diseases (HIV, hepatitis B & C)
- lung diseases (COPD, pulmonary emphysema, cystic fibrosis)
- kidney disease (insufficiency, dialysis, transplantation)
- neuromental disorders (psychosis, schizophrenia, suicide attempt)
- rare diseases
- ex-cancer patients and chronically ill people should correctly disclose the conditions they have suffered or are suffering from in accordance with the questions asked about them in this medical questionnaire. However, they may, in certain cases, enjoy a 'right to be forgotten' when applying for debt balance insurance. More information on this can be found at www.abcverzekering.be/recht-om-vergeten-te-worden

Make your choiceYesNo

I am not currently disabled or I have not been disabled for more than 1 month in the last 5 years.

Make your choiceRightIncorrect

I am not following any medical treatment or I have not followed any medical treatment with a duration of more than 3 consecutive weeks during the last 5 years.

Make your choiceRightIncorrect

I have not been hospitalised (during the last 10 years) and I should not be hospitalised in the next 12 months, undergo surgery or medical examinations.

Make your choiceRightIncorrect

Alcohol consumption : Do you confirm the 2 statements below?
a) I drink less than 2 glasses of alcohol a day on average these days
b) and, I have drunk less than 2 glasses of alcohol per day on average over the past 5 years

Make your choiceYesNo

Medical treatment : Do you confirm the 3 statements below?
(a) I am NOT following ANY medical treatment these days(1)
(b) and, I have NOT undergone any medical examination(2) in the last 12 months
c) and, I have NOT followed any medical treatment(1) longer than 3 weeks in the past 5 years

(1) "Treatment" means:
- The use of pastilles, tablets, sachets, syrups, suppositories, inhalations, intramuscular or intravenous pricks or baxters (not including the pill or other contraceptives). Does not cover trivial infections such as a flu or cold, gastrointestinal complaints with a duration of less than a week
- any other therapeutic treatment
(2) Except in the context of trivial infections such as a flu or cold, gastrointestinal complaints lasting less than a week, a check-up or a pregnancy without complications
(3) Does not cover incapacity for work due to pregnancy without complications

Make your choiceYesNo

Hospitalisation : Please confirm the 2 statements below?
(a) there is NO hospitalisation currently provided
(b) and, other than for childbirth, in the past five years I was
- NOT cared for in a hospital
- NOT hospitalised for more than 1 week
- NOT operated

Make your choiceYesNo

Periodicity of premium payments:

Monthly (or quarterly if monthly amount is too low for insurer)
Annual

Make your choiceMonthly (or quarterly if monthly amount is too low for insurer)Annual

Direct debit account number? (IBAN - mandatory for monthly premiums)

Your e-mail