Insurance Pre Assessment Tool

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Your Duty of DisclosurePlease watch the short video shown below which outlines your obligation to disclosure all relevant information on your insurance application.
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Do you consent to Everest Private Wealth collecting your personal and health information?* This field is required.By clicking yes below, you consent to Everest Private Wealth collecting and using your personal and health information in order to provide insurance recommendations to you. You also confirm you understand that any information collected will be subject to NEO Financial Solution's Pty Ltd Privacy Policy version 5 1st April 2020 which you have been provided a copy of. If you click no below, no details will be collected, however this may result in Everest Private Wealth not being able to provide you with an appropriate level of advice and service. If you choose to continue, please ensure you complete the questions as accurately as possible. If you do not provide accurate information it may result in a recommendation for insurance products that are not right for you and your circumstances, or it may result in a claim being denied if the correct information is not disclosed to an insurer.
YESNO
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Please enter your name* This field is required.
First Name
Last Name
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On what basis are you working?* This field is required.
Full-Time
Permanent Part-time
Fixed Term Contract
Casual
Unemployed
Retired
Home Duties
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What is your current occupation title?* This field is required.i.e. Business Development Manager, Builder, Doctor, Electrician
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Please advise the details of any trade, tertiary or professional qualifications you have (if any)?* This field is required.Please include TAFE certificates, undergraduate degrees, post-graduate qualifications, trade qualifications etc
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Are you self-employed?* This field is required.
YESNO
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How many hours do you work per week?* This field is required.Please enter the average number work on a typical week
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Please advise how long you have been in your current position (employer) and occupation* This field is required.
Number of years/months in current position (ie. with current employer)
Number of years/months you have performed your current occupation with your current or any employer
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Are you contemplating a change in occupation?* This field is required.Including retrenchments/redundancy, or changes in your role, duties or hours worked.
YESNO
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Please provide details
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How many hours of leave do you currently have accrued?* This field is required.
Annual Leave
Personal Leave (sick leave)
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Please provide a description of the duties you perform as part of your role, and indicate the percentage of time you spend doing each area* This field is required.e.g. Administration/office based work 50%, Supervision 10%, Driving 10%, Light manual 10% (such as equipment maintenance and stock taking), Heavy manual/trades work 20%. Please also provide percentage of time spent sitting, standing, walking, bending, climbing and kneeling.
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Does your occupation require you to work at heights above 10 metres, underground, off shore or near dangerous materials or substances?* This field is required.
YESNO
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Please provide detailsPlease include full details including (if applicable) which dangerous materials and details of safety measures employed.
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Your Height* This field is required.(in cms)
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Your Weight* This field is required.(in kgs)
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Have you lost more than 10 kgs in the last 12 months?* This field is required.
YESNO
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How much weight have you lost?
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Have you smoked any substances in the last 12 months?* This field is required.
YESNO
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Please provide smoking details below
Which substances have you smoked e.g. tobacco (cigarettes), cigars, marijuana etc
What amount do you smoke (please include over what period) e.g. 10 cigarettes per day or 1 cigar each month
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Are you an ex-smoker?* This field is required.
YESNO
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When did you cease smoking?
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Have you used recreational drugs in the last 10 years?* This field is required.For example: cannabis, ecstasy, cocaine, heroin, amphetamines or anabolic steroids
YESNO
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Please provide detailsInclude details of substance, amount used, when and how taken
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Have you experienced or been diagnosed with arthritis, bone fracture or joint injury?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Arthritis, bone fracture, joint injury
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Arthritis, bone fracture, joint injury
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with a heart condition, heart attack, rheumatic fever, chest pain, high blood pressure, raised cholesterol, vascular or circulatory disorder?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Heart condition, heart attack, rheumatic fever, chest pain, high blood pressure, raised cholesterol, vein or circulatory disorder
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Heart condition, heart attack, rheumatic fever, chest pain, high blood pressure, raised cholesterol, vein or circulatory disorder
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
32
Have you experienced or been diagnosed with cancer, tumour of any kind, cyst, growth or breast lump?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Cancer, tumour of any kind, cyst, growth or breast lump
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Cancer, tumour of any kind, cyst, growth or breast lump
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with anaemia, leukaemia, haemophilia or any other blood related disorder?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Anaemia, leukaemia, haemophilia or any other blood related disorder
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Anaemia, leukaemia, haemophilia or any other blood related disorder
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with asthma, bronchitis, a lung condition, breathing or respiratory disorder, or sleep apnoea?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Asthma, bronchitis, a lung condition, breathing or respiratory disorder, or sleep apnoea
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Asthma, bronchitis, a lung condition, breathing or respiratory disorder, or sleep apnoea
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with a disorder of the kidney, bladder or prostate, urinary complaint or kidney stone?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Disorder of the kidney, bladder or prostate, urinary complaint or kidney stone
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Disorder of the kidney, bladder or prostate, urinary complaint or kidney stone
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with a back or neck pain, disorder or issue, spinal condition, sciatica, whiplash?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Back or neck disorder or issue, spinal condition, sciatica, whiplash
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Back or neck disorder or issue, spinal condition, sciatica, whiplash
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with mental health condition, depression, anxiety, nervous condition, stress, post-traumatic stress disorder, ADHD, obsessive compulsive disorder, bi-polar disorder?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Mental health condition, depression, anxiety, nervous condition, stress, post-traumatic stress disorder, ADHD, obsessive compulsive disorder, bi-polar disorder
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Mental health condition, depression, anxiety, nervous condition, stress, post-traumatic stress disorder, ADHD, obsessive compulsive disorder, bi-polar disorder
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with chronic fatigue, fibromyalgia, fibrosis, chronic pain syndrome?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Chronic fatigue, fibromyalgia, fibrosis, chronic pain syndrome
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Chronic fatigue, fibromyalgia, fibrosis, chronic pain syndrome
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with diabetes or a thyroid related disorder?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Diabetes or a thyroid related disorder
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Diabetes or a thyroid related disorder
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with indigestion or reflux disorder, gastric or duodenal ulcer, hernia?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Indigestion or reflux disorder, gastric or duodenal ulcer, hernia, or had any tests such as x-ray, MRI, colonscopy or endoscopy
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Indigestion or reflux disorder, gastric or duodenal ulcer, hernia, or had any tests such as x-ray, MRI, colonscopy or endoscopy
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with a bowel disorder, irritable bowel syndrome, ulcerative colitis, crohn's disease * This field is required.
YESNO
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Please provide details (Illness/injury 1)Bowel disorder, irritable bowel syndrome, ulcerative colitis, crohn's disease or had any tests such as x-ray, MRI, colonscopy or endoscopy
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Bowel disorder, irritable bowel syndrome, ulcerative colitis, crohn's disease or had any tests such as x-ray, MRI, colonscopy or endoscopy
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with a gall bladder or liver disorder or hepatitis?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Gall bladder or liver disorder or hepatitis
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Gall bladder or liver disorder or hepatitis
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with epilepsy, stroke, headaches, migraines, neurological condition, disorder of the brain or nervous system, dizziness, fainting?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Epilepsy, stroke, headaches, migraines, neurological condition, disorder of the brain or nervous system, dizziness, fainting
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Epilepsy, stroke, headaches, migraines, neurological condition, disorder of the brain or nervous system, dizziness, fainting
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
68
Have you experienced or been diagnosed with a disorder of the ears, eyes or speech?* This field is required.
YESNO
69
Please provide details (Illness/injury 1)Disorder of the ears, eyes or speech
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
70
Please provide details (Illness/injury 2)Disorder of the ears, eyes or speech
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with psoriasis, eczema, dermatitis or other skin condition?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Psoriasis, eczema, dermatitis or other skin condition
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Psoriasis, eczema, dermatitis or other skin condition
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
74
Have you experienced or been diagnosed with Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency syndrome (AIDS)* This field is required.
YESNO
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Please provide details (Illness/injury 1)Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency syndrome (AIDS)
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency syndrome (AIDS)
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Have you experienced or been diagnosed with any sexually transmitted infection or disease?* This field is required.
YESNO
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Please provide details (Illness/injury 1)Any sexually transmitted infection or disease
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
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Please provide details (Illness/injury 2)Any sexually transmitted infection or disease
Name of condition/diagnosis
Date of last symptoms or details of symptoms still present
Date of initial diagnosis
Details of any time off work required e.g. number or days
Treatment received including details of any procedures or medication (mg/day)
Date of last treatment or advise if still receiving treatment or medication
80
In the past 12 months have you been prescribed medication that was intended to last for three months or longer?* This field is required.Excluding the contraceptive pill, hormone replacement, inhaled asthma medication or cold, flu or hay fever medication.
YESNO
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Please provide details (medication 1)Medication details
Diagnosis
Details of medication
Time frame required for the medication
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Please provide details (medication 2)Medication details
Diagnosis
Details of medication
Time frame required for the medication
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Have you had any tests such as X-Ray, MRI, ultrasound, CT scan, colonscopy or endoscopy that have not been discussed above?* This field is required.
YESNO
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Please provide detailsX-Ray, MRI, ultrasound, CT scan, colonscopy or endoscopy
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Have you experienced or been diagnosed with any other illness, injury, operation or disability, or will you be seeking advice or have any other outstanding tests for any thing not outlined above?* This field is required.
YESNO
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Please provide detailsInclude name of any condition diagnosed, date of any diagnosis, description & frequency of symptoms, details of any outstanding tests, treatment received or scheduled to receive, details of any time off work and details of any medication.
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In the last 10 years have you seen (or sought treatment from) a physiotherapist, chiropractor, psychologist, or any other health professional for anything you haven't already disclosed above?
YESNO
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Please provide detailsInclude name of any condition diagnosed, date of any diagnosis, description & frequency of symptoms, details of any treatment received, details of any time off work and details of any medication.
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Are you female?
YESNO
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Are you currently pregnant?
YESNO
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What is your estimated date of delivery?
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Have you ever experienced any complications with pregnancy or childbirth?
YESNO
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Please provide detailsComplications with pregnancy or childbirth
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Have you ever had an abnormal pap smear or pelvic or breast ultrasound?
YESNO
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Please provide detailsAbnormal pap smear or pelvic or breast ultrasound
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Have any of your parents, brothers, or sisters suffered from heart disease, stroke, high blood pressure, diabetes, any cancer, polycystic kidney disease, Huntington’s Chorea, inherited blood diseases, inherited brain disease, kidney failure, muscular dystrophy or other inherited disease?
YESNO
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Please provide detailsFamily history
Diagnosed person's relationship to you e.g. father
Condition or illness (if cancer, please specify type)
Age at onset
Age at death (if applicable)
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Please provide any other information about yourself, your health history or families health history that may be relevant to insurance cover.
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Do you have any definite plans to travel, live and/or work overseas in the next 12 months?
YESNO
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Please provide detailsReason (business/family/leisure), where, when, duration etc
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Have you in the last 12 months, do you currently or do you intend to take part in any of the following activities?Please select all that apply
Aviation (other than as a fare paying passenger)
Hang-gliding/hot-air ballooning/parachuting/bungee jumping/sky-diving
Competitive Motor sports (inc car, motorbike and boat etc)
Recreational Motor sports (inc trail motorbike riding etc)
Underwater diving inc scuba and free diving
Football (amateur competition/semi-professional) i.e. AFL, soccer, rugby
Martial Arts/Boxing (fitness only)
Martial Arts/Boxing (competitive)
Horseriding (recreational only)
Horseriding (including competitive/events)
Rock-climbing/Abseiling
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Please provide detailsActivity, frequency, type of equipment, depth of diving, speed of driving etc
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Have you ever claimed on any personal, accident or injury insurance or had a benefit paid under workers compensation?e.g. Income Protection payment, motor vehicle accident
YESNO
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Please provide detailsDate, amount of claim, injury or illness sustained
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