XRAE DATA CAPTURE FORM
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- Rosanna Johnson
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1 HELPING TO GATHER INFORMATION FROM YOUR CLIENT BEFORE USING XRAE This form helps you gather information from your client before you use XRAE to get an instant indicative underwriting decision. The more information you gather from your client, the more accurate the XRAE underwriting decision will be. XRAE results are indicative based on the data captured within XRAE. The rules behind the XRAE outcomes are supplied and agreed by each provider. As final outcomes may vary dependent on factors such as further medical evidence or disclosures, the rules should not be viewed as final and guaranteed but are a best case scenario on the information supplied. PARTICIPATING PROVIDERS CLIENT AND PLAN DETAILS Fields marked with an asterisk are Mandatory for XRAE to produce a quote. CLIENT NAME* CLIENT GENDER* MALE FEMALE DATE OF BIRTH* BENEFIT TYPE LIFE CRITICAL ILLNESS LIFE & CRITICAL ILLNESS LIFE SUM ASSURED* CRITICAL ILLNESS SUM ASSURED* BUILD HEIGHT feet inches centimetres WEIGHT stones pounds kilograms 1
2 TOBACCO USE Have you ever used tobacco or nicotine replacement products, including e-cigarettes? Y / N CIGARETTES Currently, or within the last 12 months - Y / N Average per day CIGARS Currently, or within the last 12 months - Y / N Average per year PIPES Currently, or within the last 12 months - Y / N Average grams / day NICOTINE REPLACEMENT PRODUCTS, INCLUDING E-CIGARETTES Currently, or within the last 12 months - Y /N ALCOHOL CONSUMPTION According to the scale provided below, please answer the following questions about your alcohol consumption. 1 glass of wine (175ml) = 2 units 1 pint of standard lager/beer = 2 units 1 measure of spirits (25ml) = 1 unit Average units of alcohol drank per week? 2
3 FAMILY HISTORY FATHER Diagnosed with Cancer? Y / N Type of Cancer (check all that apply): Prostate Testicular Melanoma Pancreatic Other - Please identify: Colon / Bowel Stomach Diagnosed with Heart Disease? Y / N Diagnosed with Diabetes? Y / N Ever had a stroke? Y / N Age at first stroke MOTHER Diagnosed with Cancer? Y / N Type of Cancer (check all that apply): Breast Cervical Fallopian Ovarian Endometrial Vaginal Vulvar Pancreatic Other - Please identify: Melanoma Stomach Colon / Bowel Diagnosed with Heart Disease? Y / N Diagnosed with Diabetes? Y / N Ever had a stroke? Y / N Age at first stroke 3
4 FAMILY HISTORY CONT... BROTHER Diagnosed with Cancer? Y / N Type of Cancer (check all that apply): Prostate Testicular Melanoma Pancreatic Other - Please identify: Colon / Bowel Stomach Diagnosed with Heart Disease? Y / N Diagnosed with Diabetes? Y / N Ever had a stroke? Y / N Age at first stroke SISTER Diagnosed with Cancer? Y / N Type of Cancer (check all that apply): Breast Cervical Fallopian Ovarian Endometrial Vaginal Vulvar Pancreatic Other - Please identify: Melanoma Stomach Colon / Bowel Diagnosed with Heart Disease? Y / N Diagnosed with Diabetes? Y / N Ever had a stroke? Y / N Age at first stroke ADDITIONAL MEDICAL INFORMATION RELATING TO FAMILY HISTORY 4
5 BLOOD PRESSURE Have you ever been diagnosed with high blood pressure? Y / N CURRENT READING Systolic / Diastolic / BLOOD PRESSURE MEDICATION Never prescribed or taken Currently used Used in past ADDITIONAL MEDICAL INFORMATION RELATING TO BLOOD PRESSURE 5
6 CHOLESTEROL Have you ever been diagnosed with raised cholesterol? Y / N TOTAL READING HDL READING (mmol/l): (mmol/l): TOTAL / HDL RATIO CHOLESTEROL MEDICATION Never prescribed or taken Currently used Used in past ADDITIONAL MEDICAL INFORMATION RELATING TO CHOLESTEROL 6
7 The following information cannot currently be entered into XRAE for an immediate indicative response, however it may be useful to gather any additional relevant information from your client. You can use this information in the XRAE messaging function to to providers or when calling the specific provider pre-sales underwriting helplines for cases where XRAE could not provide an instant quote. MEDICAL CONDITIONS Have you ever or do you currently suffer from any other medical conditions? If so, please describe them below: MEDICAL CONDITION 1 Type of condition Date diagnosed Date of last medical review Are you currently receiving treatment? Y /N Are you fully recovered? Y /N What treatment have you received? Additional notes about this condition 7
8 The following information cannot currently be entered into XRAE for an immediate indicative response, however it may be useful to gather any additional relevant information from your client. You can use this information in the XRAE messaging function to to providers or when calling the specific provider pre-sales underwriting helplines for cases where XRAE could not provide an instant quote. MEDICAL CONDITIONS CONT... Have you ever or do you currently suffer from any other medical conditions? If so, please describe them below: MEDICAL CONDITION 2 Type of condition Date diagnosed Date of last medical review Are you currently receiving treatment? Y /N Are you fully recovered? Y /N What treatment have you received? Additional notes about this condition 8
9 The following information cannot currently be entered into XRAE for an immediate indicative response, however it may be useful to gather any additional relevant information from your client. You can use this information in the XRAE messaging function to to providers or when calling the specific provider pre-sales underwriting helplines for cases where XRAE could not provide an instant quote. MEDICAL CONDITIONS CONT... Have you ever or do you currently suffer from any other medical conditions? If so, please describe them below: MEDICAL CONDITION 3 Type of condition Date diagnosed Date of last medical review Are you currently receiving treatment? Y /N Are you fully recovered? Y /N What treatment have you received? Additional notes about this condition 9
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