Medical Underwriting Questionnaire

I/We give authority for Fintor Pty Ltd to hold and disclose the information obtained within this document for the purposes of obtaining and reviewing medically underwritten insurance cover. Fintor will continue to hold the information on a secured database for the purposes of disclosure. The forms will be retained for the sole purpose of disclosure record keeping. Do you accept the privacy disclosure above in relation to Fintor Pty Ltd?

Care must be taken to answer all questions we ask as part of the insurance application honestly and accurately. The answers given in response to our questions are very important. We use them to decide if we can provide cover and, if we can, the terms of the cover and the premium we will charge.

The duty to take reasonable care not to make a misrepresentation applies any time you answer our questions as part of an initial application for insurance, an application to extend or make changes to existing insurance, or an application to reinstate insurance.

If the application is accepted the policy will be a consumer insurance contract. The Duty to take reasonable care not to make a misrepresentation is set out in most quality insurance providers PDS and Policy Terms (PDS). I am aware: of my Duty to take reasonable care; and that the Insurer will rely on the information provided by me in relation to the application.

The prospective Life Insured and Policy Owner(s) make the following declarations and authorisations, or their adviser does so on their behalf with authority from the Life Insured(s) and Policy Owner(s) (as applicable), in respect of this application for insurance:

I/We Confirm that:

1. I/we have read and understand the 'Duty to take reasonable care not to make a misrepresentation' section of this form, and I/we understand that my/our Duty to take reasonable care not to make a misrepresentation applies when answering questions as part of my application for insurance, an application to extend or make changes to existing insurance, or an application to reinstate insurance;

2. I/we understand that if the prospective Life Insured has not fully disclosed all known facts and circumstances relevant to the cover applied for, or makes a misrepresentation as to any fact or circumstance to Insurance Provider, prior to the commencement of the cover, Insurance Provider may vary the terms of the cover, reduce the amount payable in the event of claim, or avoid (cancel from when the cover commenced) the cover;

3. I/we understand the answers included in this application will influence the level and type of cover I am/we are eligible for under the terms of the insurance policy, and that any Insurance Provider may decline my/our application or offer to cover me/us on altered terms;

4. At the time of completing this application the prospective Policy Owner and/or Life Insured(s) is not receiving any benefits, eligible or entitled to receive any benefits under any other life insurance policy or compensation scheme (including without limitation any public or private workers or disability compensation scheme);

5. I/we understand that for the Insurance Provider and its service providers to comply with legislation, some correspondence will be sent to me/us as a posted letter even if I/we have nominated email or SMS as my/our preferred contact method

6. I/we authorise the Insurance Provider to:inform my/our Financial Adviser of the outcome of its assessment of my/our application, including the reasons for its decision to offer non-standard terms or decline my/our application; and
disclose any personal information (including sensitive and health information) it collects about me/us to my usual doctor;

7. the Insurance Provider can rely on any information provided by my/our financial adviser, or their representative, on my/our behalf;

8. If I/we have nominated to pay the required premium via Rollover from my/our super fund, I/we request and authorise the Trustee to transfer part of my/our nominated super fund account balance to the Insurance Provider's Superannuation Fund;

9. If I/we have nominated to pay the required premium via Direct Debit from a bank account or credit card, I/we request and authorise Stripe Payments Australia Pty Ltd ACN 160 180 343 (Direct Debit System User ID 507156) to directly debit my/our premiums, from my/our nominated account, using the Bulk Electronic Clearing System;

10. I/we acknowledge that, if I have disclosed a mobile phone contact, the Insurance Provider will send me notifications regarding my policy via SMS from time to time;

11. I/we acknowledge that the Insurance Provider's Combined Product Disclosure Statement and Policy Terms will be issued to me via email when my policy is issued;

12. I/we confirm that I/we made my/our application for the Insurance Provider whilst I was in Australia;

13. I/we understand that if my/our account has not received any contributions or other amounts for a continuous period of 16 months ("inactive"), superannuation law prohibits Equity Trustees Superannuation Limited from providing me/us with insurance cover, unless I/we make an appropriate election.

14. My/our financial adviser is acting for me/us as my/our agent, and is not the agent of the Insurance Provider;
I/we authorise my/our financial adviser to:collect, use and disclose my/our personal information (including sensitive and health information) for the purposes of management and administration of my/our application; and communicate on my/our behalf my/our acceptance of any non-standard terms offered by the Insurance Provider; Where there is any change to the authority given in point 20, I/we will notify the Insurance Provider of the change.