Questionnaire - Simple Advice TAP

1
What consultation do you want from our adviser:* This field is required.
Insurance & KiwiSaver
Just Insurance
Just KiwiSaver
Not sure yet
2
What is your full name?* This field is required.
Mr.
Mr.
Mrs.
Miss
Prefix
First Name
Middle Name
Last Name
3
What is your date of birth* This field is required.
4
What is your Gender
Please Select
Please Select
Male
Female
Diverse
5
What is your employment Status?
Please Select
Please Select
Self Employed
Full-time Employed
Part-time Employed
Sole Trader
Parent
Student
Retired
Unemployed
Deceased
6
What is your occupation
7
What is your gross annual income (NZD)?
8
What is your address? (Not PO Box)* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
What's your phone number?* This field is required.
10
What's your height?* This field is required.
11
What's your weight?* This field is required.
12
Do you have dependant(s)?* This field is required.
YESNO
13
If you want to include them in your policy, could you please provide their full name(s) and date of birth?
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Large
Normal
Small
Ok
Ok
14
What's your occupation?* This field is required.
15
Are you a business owner?* This field is required.
YESNO
16
How would you describe your business to an insurance company?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
17
How would you describe your role within your business to an insurance company?* This field is required.
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Large
Normal
Small
Ok
Ok
18
Please list the names of the company directors
19
How many staff are on your team, including yourself?* This field is required.
20
Who is the Product/Service Development Manager?Keeping abreast of market changes, new processes and developments in the industry. Responsible for leading the creation and launch of innovative products/services,
21
Who is the Marketing Manager?Analyze the competition, build and manage marketing campaigns, create brand awareness to achieve business goals.
22
Who is the Sales Manager?Driving sales growth, managing customer relationships, setting sales targets, analyzing performance data, and implementing strategies to achieve sales objectives.
23
Who is the Operations Manager?Overseeing daily business operations, managing workflow, coordinating with sub-contractors and staff, optimizing processes, allocating resources, ensuring efficiency
24
Who is the Finance Manager?Budgeting, financial planning, analyzing financial data, managing business resources, and making strategic decisions to ensure financial stability and growth
25
Who is the Admin Manager?Oversee daily office operations, managing administrative tasks, coordinating office resources, supervising staff, and handling invoicing and debtor management.
26
Who is the Human Resource Manager?Manage HR Operations including recruitment, employee relations, training, and ensuring health and safety compliance.
27
How many hours do you work per week?:* This field is required.
28
How many hours do you work from home?Click next if not applicable
29
How many hours of manual physical work do you do per week ?* This field is required.
30
Do you own your own home?* This field is required.
YESNO
31
Does your home have a mortgage?* This field is required.
YESNO
32
Which bank is your loan with?* This field is required.
Please Select
Please Select
ANZ
BNZ
ASB
Westpac
KiwiBank
Other
33
As you have selected another bank, could you tell us which one?* This field is required.
34
What is the total value of your home mortgage?* This field is required.
35
What are the total monthly repayments? * This field is required.
36
Do you have a rental property?* This field is required.
YESNO
37
What is the address of the rental?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
38
What was the purchase price?* This field is required.
39
What is the current value?* This field is required.
40
What is the total value of your rental mortgage?* This field is required.
41
How much is the rental income per month?* This field is required.
42
What are the monthly mortgage payments?* This field is required.
43
What is your IRD Number?If you don't know, just click next
44
Do you currently have KiwiSaver?* This field is required.
YESNO
45
Who is your current provider?* This field is required.
46
What is your Current Balance
47
What is the most important to you in a provider?* This field is required.
Please Select
Please Select
Proven track record in managing wealth
NZ owned and operated
High Focus on Customer service
Ethical Investor / Socially Responsible Investor
Multiple fund choices
Being government default provider option
Good Returns for the past 5-10 years
48
What do you like about your current provider?* This field is required.
Please Select
Please Select
Proven track record in managing wealth
NZ owned and operated
High Focus on Customer service
Ethical Investor / Socially Responsible Investor
Multiple fund choices
Being government default provider option
Good Returns for the past 5-10 years
49
What is your PIR?* This field is required.
10.5% [ your taxable income $14,000 or less & Your total Income $48,000 or less]
17.5% [ your taxable income $48,000 or less & Your total Income $70,000 or less]
28% [ Your taxable income $48,000 or More & Your total Income $70,000 or more]
50
What is your priority in Kiwi Saver?
Retirement
First Home
51
When do you aim to purchase your first home ?
0-3 years
4-8 years
9+ years
52
If your portfolio fell 10% in a year, how would you react?
Please Select
Please Select
Panic and want out quickly
Feel uncomfortable but I would hold the course
This is acceptable in pursuit of long-term gains
53
Would you prefer:
Please Select
Please Select
Very low risk even if returns are lower
Balanced risk/return
Willing to take higher risk for higher long-term return
54
If markets drop sharply and stay down for a few months, you:
Very Uneasy
Some anxiety but long term plan unchanged
Not worried at all
55
How do you rate your investment knowledge?* This field is required.
Very little
I have some knowledge
Sophisticated
56
How often do you check your investments?* This field is required.
All the time
Every now and then
Hardly ever
57
Are you currently taking any medication?* This field is required.
YESNO
58
What medication are you taking and why was it prescribed?* This field is required.
59
Do you smoke or vape?* This field is required.
YESNO
60
Please enter your GP name and your medical centre* This field is required.Type don't know if you're not sure
61
Have any of your immediate family members (parents, siblings) faced any of the following illnesses?If not, just click next
Any form of cancer, including breast, ovarian, bowel, leukaemia, lymphoma
Type 1 or type 2 diabetes
Any heart disease or disorder
Any neurological condition, including multiple sclerosis, motor neurone disease, muscular dystrophy, Alzheimer's disease
Polycystic kidney disease (PKD)
Stroke
Huntington's disease
Any other hereditary or familial condition (not including conditions already listed above)
62
Have you faced any of the following conditions?If not, just click next
Cancer
Asthma
Any form of arthritis?
Major musculoskeletal (e.g. Shoulder reconstruction)
Diabetes (Type 1 or 2)
Heart or arteries
High blood pressure
Anxiety or depression
Any other condition (not including conditions already listed above)
63
As you have ticked on "Cancer" we will need a little extra information.
64
As you have ticked on "Asthma" we will need a little extra information.
65
As you have ticked on "Arthritis" we will need a little extra information.
66
As you have ticked on "Major musculoskeletal" we will need a little extra information.
67
As you have ticked on "Diabetes" we will need a little extra information.
68
As you have ticked on "Heart or arteries" we will need a little extra information.
69
As you have ticked on "High blood pressure" we will need a little extra information.
70
As you have ticked on "Anxiety or depression" we will need a little extra information.
71
As you have ticked on "Other" we will need a little extra information.
72
If you have it handy, could you please attach a copy of your ID?
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
73
If you have it handy, could you please attach a copy of your insurance policy?If applicable
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
74
How would you prefer to be contacted?* This field is required.
Call
Email
SMS
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