Personal Insurance Medical Pre-Assessment

As part of any application for personal insurances (e.g. life cover, TPD, trauma and income protection cover etc.) you will be required to answer a series of medical questions. Your answers to these questions will influence the terms upon which the insurer offers you cover.

To allow us to ensure you are able to obtain the best terms available for your required cover, it would be appreciated if you could answer the below questions as honestly as possible. We will then use this information to explore your options with various insurers. This ensures we are able to recommend the most appropriate provider for you.

If you do not feel comfortable answering any of these questions, please leave them blank. However, be aware that this may impact our ability to provide the appropriate insurance cover for your needs.

Name

Gender

Age

years

Occupation

Do you have any professional or trade qualifications?

No Yes

Please outline your highest qualification

In the last 5 years, have you been either declared bankrupt or put under any form of personal insolvency administration or if you've been a business owner, has your business ever been insolvent or placed into any form of insolvency or external administration?

No Yes

Please provide further details

What is your base salary before tax?

Is your current income more than 10% higher than the previous two financial years?

No Yes

Please provide what your income was for the two prior financial years

Do you receive any bonus or commissions as part of your remuneration?

No Yes

Please provide further details on bonus or commissions you typically receive

How much sick/annual/long service leave do you have?

Sick Leave

days

Annual Leave

days

Long Service Leave

days

Height

Weight

Have you smoked, or used any nicotine product in the past 12 months (i.e. vape, nicotine patch/gum)?

No Yes

How many cigarettes would you smoke per day?

Do you drink alcohol?

No Yes

How many drinks would you average per day?

Do you take, or have you taken any recreational drugs in the past?

No Yes

What drugs have you taken and when was the last time you took them?

Do you take part in any dangerous hobbies or pastimes?

No Yes

Please outline what activities you participate in (i.e. skydiving, rock-climbing, trail bike riding)

Do you take any medication, or have you taken any medication in the past 3 years?

No Yes

What do you take, how often do you take it, and what do you take it for?

If you are human, leave this field blank.