Forms to be completed will be sent by email

PART A – PERSONAL DETAILS

Surname_________________________ Forename(s)

Home Address

___________________________________________________________Postcode

Telephone Email

Date of Birth_____________________

PART B - MEDICAL REVIEW

Please answer the following questions. If you answer “Yes” to any of the questions please provide details in the box at the bottom of this section.

Have you had a coronary thrombosis (heart attack) or

have undergone heart surgery?

Yes No

Are you liable to epileptic seizures or sudden

disturbances of the state of consciousness?

Yes No

Do you suffer problems with heart rhythm, or have a

disease of the heart or arteries?

Yes No

Do you have abnormal blood pressure that is not well

controlled with drugs?

Yes No

Do you have diabetes?

Yes No

Have you had a stroke, or unexplained loss of

consciousness?

Yes No

Have you had a severe head injury with continuing

impairment?

Yes No

 

MEDICAL QUESTIONNAIRE

 

Do you suffer from parkinson's disease or multiple

sclerosis?

Yes No

Are you being treated for psychological or nervous

problems?

Yes No

Have you had an alcohol or drug dependency problems

within the last 5 years?

Yes No

Do you have profound deafness or any other impairment

which affects your ability to communicate clearly on the

radio/telephone?

Yes No

Do you suffer from double or tunnel vision?

Yes No

Do you have any other condition which could have an

adverse effect on your ability to participate in this even.t

Yes No

If you have any additional information you would like to provide to support this Medical Questionnaire or inresponse to the above questions please use this space:

 

 

 

PART C - DECLARATION

I declare that I have checked the details given on the enclosed form and that to the best of my

knowledge and belief they are true and correct. I also authorise Calabaza Sailing l  to disclose the information in

this form to the Calabaza Sailing  Insurance Assessor  and agree to submit to a medical examination if requested by

the Insurance

Signature of Applicant_________________________________ Date__________________

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