Personal Accident & Illness Insurance Needs Analysis
Broker Email Address - a copy of the form will be sent to this address
*
example@example.com
Client Reference
*
Date of Enquiry
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Policy Due Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Current Insurer
Who referred client?
Sales Team
Insured Details
Insured Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Income
Client Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: 0000000000.
Gender
Please Select
Male
Female
Smoker
Please Select
Yes
No
Weight (kg)
Height (cm)
Occupation
Experience (years)
Nature of Activities
Travel extensively or reside outside Australia during policy period?
Claims History
For last 5 years (include property damage, theft & fire claims)
Claim #1
Insurer
Date of Loss
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Details of Claim #1
Amount
Claim #2
Insurer
Date of Loss
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Details of Claim #2
Amount
Claim #3
Insurer
Date of Loss
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Details of Claim #3
Amount
Insurance History
Rows
Yes or No
Has the Insured previously held any personal accident or illness insurance policy? If yes, provide details below
Yes
No
Has the Insured ever had insurance cancelled, declined or special conditions imposed?
Yes
No
Has the Insured ever been charged or convicted of any criminal offence?
Yes
No
Has the insured or any drivers ever been declared bankrupt or been placed in receivership?
Yes
No
If Yes, Provide Full Details
Medical Details
Rows
Yes or No
Would the Insured have any cause to consider themselves not in good health?
Yes
No
Is the Insured currently taking any prescription medication?
Yes
No
Has the Insured been treated by a registered medical practitioner for any injury/illness in the last 5 years, that required hospitalization, time off work or ongoing treatment?
Yes
No
If Yes, Provide Full Details
Has the Insured suffered from any injury to, or illness or disease of, relating to
Rows
Yes or No
Heart, lungs, respiratory system, high blood pressure, circulatory disorder, rheumatic fever or diabetes?
Yes
No
Bones, joints, muscles, arthritic condition, limbs or skin?
Yes
No
Kidney, urinary tract or reproductive organs?
Yes
No
Head, back, slipped disc or other spinal disorder or neck?
Yes
No
Brain, nervous system or auto-immune system?
Yes
No
Stomach, bowel or digestive system?
Yes
No
Eyes, ears, nose or throat (other than infrequent colds)? (includes defective sight & hearing)
Yes
No
A hernia?
Yes
No
Any infectious disease or viral infection (other than infrequent colds)?
Yes
No
Any mental illness or disease, clinical depression, any nervous or stress-related condition?
Yes
No
Any other injury, illness or disease?
Yes
No
If Yes, Provide Full Details
Hazardous Activities
Does the Insured engage in any hazardous pastimes or activities? (e.g. rock climbing/snow skiing/motor cycling/football/motor sports etc)
Please Select
Yes
No
If Yes, Provide Full Details
Details of Cover
Details of Cover
Please Select
24 hours- 365 days per year
Outside working hours only
Working Hours Only
Scope of cover - Excess Period
Please Select
Nil
7 Days
14 Days
21 Days
Scope of cover - Benefit Period
Please Select
52 Weeks
104 Weeks
Benefits Required
Capital & Accidental Death
$
Weekly – Accident/Injury
$
Weekly – Sickness/Illness
$
Other
$
Broker Recommendations
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