Insurance Review Questionnaire

1
Please provide your name* This field is required.
First Name
Last Name
2
Have there been any changes to your family situation?* This field is required.i.e. new children born, child/ren left school, left home or moved back home or any other significant family matters that are affecting your finances or life.
YESNO
3
Please provide details
4
Have you suffered any injuries such as broken bones or joint injuries since taking out your insurance?* This field is required.
YESNO
5
Please provide details
6
Have you had any other changes to your health or had treatment for medical conditions since taking out your insurance?* This field is required.
YESNO
7
Please provide details of any injuries or medical issues/treatment
Huge
Large
Normal
Small
Ok
Ok
8
Has your weight changed by more than 10kgs since your previous insurance review?* This field is required.
YESNO
9
Please provide your current weight
10
Has your smoking status changed since taking out your insurance?* This field is required.
YESNO
11
Please provide details of the changes to your smoking statusi.e. quit smoking, when you had your last smoke, etc.
12
Are you aware of any loadings or exclusions on your current insurance policies that you wish to review?* This field is required.For example, back exclusion, mental health exclusion, loading due to BMI, etc.
YESNO
13
Please list the current loadings or exclusions you are aware of, and provide us with an update of these medical issues for our review.i.e. no back pain for 2 years, lower BMI, test results where you are back in a normal range, etc.
Huge
Large
Normal
Small
Ok
Ok
14
Have there been any changes to your employment circumstances or do you expect any upcoming changes?* This field is required.i.e. changes to your job, changed employer, changes to job security and/or enjoyment
YESNO
15
Please provide details
16
Has there been a substantial increase or decrease to your income, or are there changes expected in the near future?* This field is required.i.e. increase or decrease of more than 5%
YESNO
17
Please provide details
18
Have you increased or decreased your rate of savings or capacity to save?* This field is required.
YESNO
19
Please provide details
20
Do you foresee any major expenditure in the next 12 months?* This field is required.
YESNO
21
Please provide details
22
Have there been any changes to your financial position?* This field is required.
Please Select
Please Select
Yes
No
Have you purchased or sold any investments or major personal assets?
Please Select
Please Select
Yes
No
Have you reduced or increased debt?
Please Select
Please Select
Yes
No
Have you received a lump sum payment or inheritance?
23
Please provide details
24
Have you implemented any new or cancelled any personal life/disability insurances?* This field is required.
YESNO
25
Please provide details
26
Do you believe your current premiums remain affordable?* This field is required.
YESNO
27
Are you intending to retire in the next 5 years?* This field is required.
YESNO
28
Would you like to discuss retirement planning with your adviser?* This field is required.
YESNO
29
Do you have an up-to-date Will that reflects your current wishes?* This field is required.
YESNO
30
Are you comfortable that all other aspects of your estate plan are adequate? * This field is required.e.g. family trust deed if applicable, superannuation death benefit nominations
YESNO
31
What area/s do you believe require updating or attention?
32
Have you implemented an Enduring Power of Attorney to allow financial decisions to be made on your behalf in the event you are mentally incapacitated?* This field is required.
YESNO
33
Please provide details of any other relevant changes to your circumstances not outlined above
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: