Insurance Pre-assessment
Personal Insurance (Life, TPD, Income Protection & Trauma)
Name
*
First Name
Last Name
Email
*
example@example.com
Gender
*
Please Select
Male
Female
Prefer not to disclose
Height (cm)
*
Weight (kg)
*
Phone Number
Phone Number
Date of Birth
*
/
Day
/
Month
Year
Date
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Employment Details
Have you worked in the same occupation for 12 months?
*
Yes
No
Previous occupation?
*
Current Employment Status
*
Please Select
Full-time
Part-time
Self-employed
Contract
Casual
Unemployed
Other
Start date of employment
*
/
Day
/
Month
Year
Closest to the month
Do you work at heights above 10m?
*
Please Select
Yes
No
What percentage of your time is spent working at heights above 10m
*
Do you work with explosives?
*
Please Select
Yes
No
What percentage of your time is spent working with explosives?
*
Have you or any business that you have been associated with:
*
Been made bankrupt
Placed into receivership
Placed in involuntary liquidation
Placed under administration
Contemplating voluntary administration
Not applicable
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Additional Details
Have you smoked tobacco, e-cigarettes (vaping) or any other substance in the last 12 months?
*
Yes
No
In the last 10 years, have you used any recreational drug not prescribed for you by a doctor?
*
Yes
No
Recreational drug used:
*
Method used:
*
Month/Year for last date used:
*
Do you take regular medication?
*
Yes
No
How many different medications do you take regularly?
*
Please Select
1.
2.
3.
4.
5.
6.
7.
8.
9.
10+
1. Medication Name
*
1. What does the medication treat?
*
1. Dosage
*
1. Frequency
*
1. Date of diagnoses
*
-
Day
-
Month
Year
Date
1. Date of last symptoms
*
-
Day
-
Month
Year
Date
2. Medication Name
*
2. Dosage
*
2. Frequency
*
2. What does the medication treat?
*
2. Date of diagnoses
*
-
Day
-
Month
Year
Date
2. Date of last symptoms
*
-
Day
-
Month
Year
Date
3. Medication Name
*
3. Dosage
*
3. Frequency
*
3. What does the medication treat?
*
3. Date of diagnoses
*
-
Day
-
Month
Year
Date
3. Date of last symptoms
*
-
Day
-
Month
Year
Date
4. Medication Name
*
4. Dosage
*
4. Frequency
*
4. What does the medication treat?
*
4. Date of diagnoses
*
-
Day
-
Month
Year
Date
4. Date of last symptoms
*
-
Day
-
Month
Year
Date
5. Medication Name
*
5. Dosage
*
5. Frequency
*
5. What does the medication treat?
*
5. Date of diagnoses
*
-
Day
-
Month
Year
Date
5. Date of last symptoms
*
-
Day
-
Month
Year
Date
6. Medication Name
*
6. Dosage
*
6. Frequency
*
6. What does the medication treat?
*
6. Date of diagnoses
*
-
Day
-
Month
Year
Date
6. Date of last symptoms
*
-
Day
-
Month
Year
Date
7. Medication Name
*
7. Dosage
*
7. Frequency
*
7. What does the medication treat?
*
7. Date of diagnoses
*
-
Day
-
Month
Year
Date
7. Date of last symptoms
*
-
Day
-
Month
Year
Date
8. Medication Name
*
8. Dosage
*
8. Frequency
*
8. What does the medication treat?
*
8. Date of diagnoses
*
-
Day
-
Month
Year
Date
8. Date of last symptoms
*
-
Day
-
Month
Year
Date
9. Medication Name
*
9. Dosage
*
9. Frequency
*
9. What does the medication treat?
*
9. Date of diagnoses
*
-
Day
-
Month
Year
Date
9. Date of last symptoms
*
-
Day
-
Month
Year
Date
10. Medication Name
*
10. Dosage
*
10. Frequency
*
10. What does the medication treat?
*
10. Date of diagnoses
*
-
Day
-
Month
Year
Date
10. Date of last symptoms
*
-
Day
-
Month
Year
Date
In the last 12 months, have you seen a medical specialist? E.g. Physiotherapist, cardiologist, psychologist or neurologist
*
Please Select
Yes
No
Type of specialist?
*
Why did you see them?
*
What was the treatment provided?
*
How frequently were you getting treatment?
*
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Additional Medical Issue / History Notes
*
Additional Occupation & Potential Risks Notes
*
Disclosure: The duty to take reasonable care
When applying for insurance, there is a legal duty to take reasonable care not to make a misrepresentation to the insurer before the contract of insurance is entered into. A misrepresentation is a false answer, an answer that is only partially true, or an answer which does not fairly reflect the truth. The duty also applies when extending or making changes to existing insurance, and reinstating insurance. If you do not meet your duty If you do not meet your legal duty, this can have serious impacts on your insurance. Your cover could be avoided (treated as if it never existed), or its terms may be changed. This may also result in a claim being declined or a benefit being reduced. Please note that there may be circumstances where the insurer later investigates whether the information given to them was true.
I confirm I have answered the above questions to the best of my knowledge and have taken reasonable care to not make a misrepresentation regarding my situation.
*
I confirm
Submit
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