Medical Underwriting Questionnaire

  • Medical Underwriting Questionnaire

    This form will ask all questions which is required for the application to be lodged with an insurance provider OR a medical pre-assessment to be performed.
  • Format: 0400 000 000.
  • What is your date of birth?*
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  • What is your sex?*
  • What is your employment status?*

  • Duty of Disclosure

    Once you have agreed to your duty of disclosure you are able to continue with the medical information gathering form.

  • 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?

  • Do you agree?*

  • 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.

  • Do you agree?*

  • 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.

  • Do you agree?*

  • Your Basic General Information

  • Have you smoked, vaped or used any smoking alternatives in any of the following periods?*
  • Have you ever used any drugs or medication that were not prescribed for you by a medical practitioner (including prescription, recreational and designer drugs)?*
  • Do you intend to travel or live outside of Australia in the next 12 months?*
  • Do you participate, or intend to participate, in any of the following:*
  • Are you a reservist in the armed forces or other volunteer emergency service?*
  • Have you ever had an application for Life, TPD, Trauma or Income Protection insurance declined, modified or offered on non-standard terms?*
  • Are you claiming or have you ever made a claim for sickness, accident or disability benefits, workers compensation or any other form of compensation due to illness or injury?*
  • Do you consent to us calling you for any further information?*

  • Family Medical History

  • Have you had a biological parent, sister or brother experience any of the following conditions under the age of 55? Please tick all that apply.*
  • Have you ever had, or are you awaiting the results of, a genetic test?*
  • Cancer - What type of cancer have any of your parents, brothers or sisters had?*
  • Bowel/Colorectal Cancer - Have you had a colonoscopy with normal results in the last 2 years?*
  • Bowel/Colorectal Cancer - How many of your parents, brothers or sisters have been diagnosed with Bowel/Colorectal Cancer?*
  • Breast or Ovarian Cancer - Have you had prophylactic or preventative surgery?*
  • Breast or Ovarian Cancer -What preventative surgery have you undergone?*
  • Breast or Ovarian Cancer - How many of your parents, brothers or sisters have been diagnosed with Breast or Ovarian Cancer?*
  • Cardiomyopathy - What type of Cardiomyopathy has your family member(s) been diagnosed with?*
  • Cardiomyopathy - Have you had any cardiac investigations?*
  • Cardiomyopathy - Did you have a normal echocardiogram and electrocardiogram?*
  • Diabetes - Are any of these family members your identical twin?*
  • Diabetes - What type of diabetes was your twin diagnosed with?*
  • Muscular Dystrophy - What type of Muscular Dystrophy has your family member(s) been diagnosed with?*
  • Polycystic Kidney Disease - Have you had any tests or investigations due to your family history*
  • Polycystic Kidney Disease - Were you diagnosed with polycystic kidney disease or kidney cysts?*

  • Your Personal Medical History

  • Has your weight increased or decreased by more than 10 kilograms in the last 12 months?*
  • Please select the reason your weight changed:*
  • Please select the reason your weight changed:*
  • Raised blood pressure (including making diet and lifestyle changes to improve your blood pressure)?
  • Blood Pressure - Was your high blood pressure caused by: the oral contraceptive pill or due to pregnancy?*
  • Blood Pressure - Has your blood pressure returned to normal?*
  • Blood Pressure - When were you advised that your blood pressure had returned to normal?*
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  • Blood Pressure - When were you diagnosed with high blood pressure?*
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  • Blood Pressure - How is your high blood pressure treated?*
  • Blood Pressure - How often do you have your blood pressure checked by a doctor?*
  • Blood Pressure - When was your most recent reading?*
     - -
  • Blood Pressure - Do you know your most recent blood pressure reading?
  • Blood Pressure - Are you currently waiting for any tests or test results?*
  • Raised cholesterol (including making diet and lifestyle changes to improve your cholesterol)?*
  • High Cholesterol - When did you first receive advice for or experience symptoms of raised cholesterol?*
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  • High Cholesterol - What treatment plan have you undergone (or are still undergoing) for your raised cholesterol?*
  • High Cholesterol - When did you last have your cholesterol tested?*
  • High Cholesterol - Do you recall your last reading?*
  • High Cholesterol - Have you been advised that your triglycerides are elevated?*
  • Diabetes, sugar in your urine, raised blood sugar levels or HbA1c?*
  • Diabetes - Please select the option that applies to you:*
  • Diabetes - Are you currently on medication?*
  • Diabetes - When were you first diagnosed?*
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  • Diabetes - When did you last have a check-up with your doctor for your diabetes or elevated sugar levels?*
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  • Diabetes - Have you experienced any complications related to your diabetes (such as retinopathy, neuropathy, nephropathy)?*
  • Gestational Diabetes - When were you first diagnosed?*
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  • Gestational Diabetes - Did you have a check up relating to your raised blood sugar levels after you gave birth?*
  • Gestational Diabetes - Has your doctor told you that you no longer have gestational diabetes or diabetes?*
  • Gestational Diabetes - Do you require treatment for your GDM or blood sugar levels?*
  • Gestational Diabetes - Have you had treatment for your gestational diabetes or blood sugar levels?
  • Gestational Diabetes - Has your doctor advised that you don't need any follow ups for your blood sugar levels?
  • Gestational Diabetes - When did you last have a check-up with your doctor for your diabetes/blood sugar levels?
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  • Any disorder of the thyroid (including but not limited to underactive or overactive thyroid, Hashimoto's disease)?*
  • When were you diagnosed with this condition?*
     - -
  • Any disorder of the kidney or bladder (including but not limited to blood or protein in the urine, urinary tract infections or kidney stones)?*
  • When were you diagnosed with this condition?*
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  • Any heart condition or disease (including but not limited to heart attack, stroke, irregular heartbeat, heart murmur, chest pain or angina)?*
  • When were you diagnosed with this condition?*
     - -
  • Any disorder of the blood (including but not limited to anaemia or haemophilia)?*
  • When were you diagnosed with this condition?*
     - -
  • Multiple sclerosis, Parkinson's disease, Alzheimer's disease, dementia, paralysis or cerebral palsy?*
  • When were you diagnosed with this condition?*
     - -
  • Epilepsy, any fit or blackout, or recurrent headaches including migraines?*
  • When were you diagnosed with this condition?*
     - -
  • Stroke, transient ischaemic attack (TIA), brain haemorrhage or any brain injury?*
  • When were you diagnosed with this condition?*
     - -
  • Any neurological complaint or disorder of the nervous system (including but not limited to dizziness, involuntary shaking, memory loss, loss of feeling, weakness, or tingling of limbs of face)?*
  • When were you diagnosed with this condition?*
     - -
  • Depression, Post-Traumatic Stress Disorder, behavioural or mood disorders, anxiety, anxiety disorders, eating disorders, schizophrenia, personality or psychotic disorders, chronic pain, chronic fatigue or any form of psychological or mental health condition?*
  • Mental Health - What condition(s) have you been diagnosed with, or sought medical advice or treatment for? (Please tick all that apply)*
  • Mental Health - Was this a single episode that lasted six months or less?*
  • Mental Health - When did you last experience symptoms?*
  • Mental Health - What treatment did you receive? Please tick all that apply*
  • Consultation with GP - When did you last receive this treatment?*
  • Consultation with Specialist - When did you last receive this treatment?*
  • Medication - When did you last receive this treatment?*
  • Mental Health - Have you ever experienced psychosis or attempted self harm or suicide?*
  • Mental Health - Have you required more than 1 week off work for this condition, or any change to your normal working hours or duties in the past 10 years?*
  • Cancer, tumour, leukaemia, Hodgkin's disease, lymphoma, melanoma or skin cancer, or any malignant or cancerous condition?*
  • Cancer - Are you currently awaiting any tests or test results?*
  • Cancer - When were/are these tests?*
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  • Cancer - When were you diagnosed?*
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  • Cancer - Have you ever had, received advice for, or experienced symptoms of any other cancer, tumour, leukemia, Hodgkin's disease, lymphoma, melanoma or skin cancer, or any malignant or cancerous condition?
  • Cancer - When were you diagnosed with this condition?*
     - -
  • Have you ever had a breast lump, thickening, unexplained pain or changes to the breast or nipple or abnormal investigations such as mammogram or ultrasound?*
  • When were you diagnosed with this condition?*
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  • Any cyst, growth, lump or skin lesion?*
  • When were you diagnosed with this condition?*
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  • Any mole or freckle that has bled, become painful, changed colour or increased in size?*
  • When were you diagnosed with this condition?*
     - -
  • Any disorder of the skin including psoriasis, eczema, or dermatitis?*
  • When were you diagnosed with this condition?*
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  • Any abnormal pap smear results?*
  • Abnormal Pap Smear - Are you currently awaiting any tests or test results?*
  • Abnormal Pap Smear - When were/are these tests?*
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  • Abnormal Pap Smear - Was the abnormal result a false positive?*
  • Abnormal Pap Smear - Do you recall the grading/severity?*
  • Abnormal Pap Smear - What was the grading/severity?
  • Abnormal Pap Smear - What type of treatment were you advised to have?*
  • Abnormal Pap Smear - Have you ever had, received advice for, or experienced symptoms of any other abnormal pap smears?*
  • Any gynaecological conditions such as fibroids, endometriosis, ovarian cysts, polycystic ovarian syndrome, hysterectomy or any menstrual irregularities or disorders?*
  • When were you diagnosed with this condition?*
     - -
  • Raised PSA reading?*
  • Raised PSA - Has the raised PSA reading been fully investigated?*
  • Raised PSA - Was the cause identified?*
  • Raised PSA - What was the diagnosis?*
  • Raised PSA - Have you undergone surgery or endoscopic resection?*
  • Raised PSA - Was the benign diagnosis confirmed by the pathology report or your specialist following this surgery?*
  • Raised PSA - Are you experiencing any ongoing symptoms or do you have any pending treatment?*
  • Raised PSA - Are you awaiting any further test results?*
  • Breathing difficulties, asthma, ongoing or regular bronchitis, sleep apnoea, pneumonia or any other lung or respiratory disorder?*
  • When were you diagnosed with this condition?*
     - -
  • Any disorder of the digestive system, gall bladder, stomach, bowel or liver including hepatitis A (including but not limited to gastric or duodenal ulcer, colitis, Crohn's disease, hernia, irritable bowel syndrome, or any change to your usual bowel habits)?*
  • When were you diagnosed with this condition?*
     - -
  • Have you ever tested positive or you are awaiting the results of any related tests for any of the following: HIV, Hepatitis B, Hepatitis C?*
  • When were you diagnosed with this condition?*
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  • Back or neck pain, spine surgery injury or disorder including slipped disc, sciatica, whiplash or any other disorder of the neck, middle or lower back?*
  • Any pain, disorder, injury, deformity or disease of any joint, bone or limb including muscles, ligaments and tendons?*
  • Any disorder of the eyes including keratoconus, blurred or double vision (other than short or long sightedness)?*
  • When were you diagnosed with this condition?*
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  • Any disorder of the ears or speech including hearing loss or tinnitus?*
  • When were you diagnosed with this condition?*
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  • Are you planning any elective surgery in the next 12 months?*
  • Have you tested positive for, or are you awaiting test results for COVID-19 (novel Coronavirus / SARS-COV-2)?*
  • What date did you contract COVID19?
     - -
  • Did you require any hospitalisation, ventilationor in-patient treatment? Have you now been fully recovered (meaning allassociated symptoms ceased and you were able to return to your normal dailyactivities) for at least 1 month*
  • Apart from what you've already told us, are you considering, or have you been told to have any investigations, treatment, or ongoing prescribed medication?*
  • Apart from what you've already told us, have you had any surgery in the last 5 years, or are you awaiting surgery?*

  • Financial Information

  • Have you ever been declared bankrupt?*
  • Bankruptcy - When were you declared bankrupt?*
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  • Bankruptcy - Has your bankruptcy ended?*
  • Bankruptcy - When did your bankruptcy end?*
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  • Bankruptcy - Was this bankruptcy voluntary?*
  • Bankruptcy - Were you an employee or self-employed at the time of the bankruptcy?*
  • Bankruptcy - Were you subject to any legal action as part of this bankruptcy?*
  • Bankruptcy - Prior to this bankruptcy, had you ever been declared bankrupt before?*
  • Employee - Has there been more than a 20% difference in your income from the previous financial year?*
  • Employee - What was the reason for this difference:*
  • Employee - In the last 6 months have you been stood down, placed on unpaid leave or made redundant, or have there been any changes to your occupation duties, hours worked or income?*
  • Employee - Have you been made aware of any changes to your employment status, usual occupation duties, hours worked or income that may occur within the next 6 months?*
  • Employee - Have you taken 6 weeks or more off work for any reason other than annual leave, long-service leave or parental leave?*
  • Employee - How long have you been in your current main occupation?*
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  • Employee - Are you intending to change your occupation within the next 12 months?*
  • Employee - Do you have any other occupations?*
  • Self Employed - How long have you been operating your current business?*
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  • Self Employed - Have you taken 6 weeks or more off work for any reason other than annual leave, long-service leave or parental leave?*
  • Self Employed - Have you been made aware of any changes to your employment status, usual occupation duties, hours worked or income that may occur within the next 6 months?*
  • Self Employed - Do you work from home?*
  • Self Employed - Has there been more than a 15% difference in your income from the previous financial year?*
  • Other Employment - When completing your personal details you selected your employment type as 'non-working'. Please indicate which of the following best describes your current circumstances*

  • Final Page

  • Do you want to upload any medical documents to assist in the assessment of your health for the purposes of insurance?*
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  • Is there any additional information you would like to disclose in regards to your application or medical history?*
  • Please confirm that all information within this form remains to be true and accurate, being in line with your duty of disclosure?*
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