Health Questionnaire -

Life Insurance Details

Title: *

Given Name(s): *

Surname: *

Date of Birth (day): * Date of Birth (month) * Date of Birth (year) *

Gender: *

Address: *

Suburb: *

State: *

Postcode: *

Home Phone Number: *

Work Phone Number:

Mobile Phone Number:

Email Address: *

Marital Status: *

Country of Birth: *

Insurance Product

Insurance Product: *

Life
TPD
Trauma
Income Protection

Occupation

What is your occupation (and industry)? *

Details of relevant qualifications held *

Brief summary of duties? *

Work hours per week? *

Percentage of manual work (including driving)? *

Currernt annual work earnings before tax? *

Height/Weight

What is your height? *

What is your weight? *

Smoking

In the last 12 months have you smoked tobacco or any other substance, or used any nicotine containing product?*

Alcohol

On average how many standard glasses of alcohol do you consume per day?*

Travel

Have you any intention of living or travelling outside of Australia/New Zealand?*

Hazardous Pursuits

Do you, or are you likely to, take part in any hazardous activities? Examples of hazardous activities include: private aviation, motor sports, scuba diving, sailing, body contact sports such as martial arts or football and recreations involving heights or underground activities?*

Are you a member of the armed forces either full or part time?*

Existing or Pending Cover

Excluding this application, do you have or are you applying for life cover, medical recovery insurance or disability cover which you are not replacing? If yes, please provide details of insurer, sum insured and commencement date.

Have any proposals for life, medical recovery, total permanent disablement or disability cover in your life ever been declined, deferred or offered on non-standard terms?*

Have you ever received compensation payments for an accident, sickness or disability or is there a current claim being made?*

Family History

Medical History

Have you ever used illegal drugs or received advice and/or counselling for excess alcohol consumption from any health professional? *

Females Only

Have you ever had any complications with pregnancy or childbirth?

If yes, please provide details:

Are you currently pregnant?

Have you ever had an abnormal cervical smear test(PAP), breast ultrasound or mammogram?

If yes, please provide details:

Have you ever had any symptoms of or sought advice or treatment for any condition of the cervix, ovary, uterus, breast or endometrium?*

If yes, please provide details:

Other Medical

Have you ever tested positive for HIV/AIDS, Hepatitis B or C, or any other sexually transmitted illness or are you awaiting the results of such a test (other than for this application)?*

Yes
No
Waiting for results

Have you in the last five years been absent from work or your place of study for a period of greater than five days through any illness or injury not previously disclosed in this application?*

Are you suffering from any symptoms of illness, undergoing counselling, taking pills, drugs or medicine, have you any physical defect or infirmity, or in the last five years have you undergone any medical investigation or test (eg generic test, mammogram)?*

Do you contemplate seeking medical advice, investigation or treatment (including surgery) for any current health problem not already disclosed?*

Doctor Details

First Name: *

Surname: *

Clinic/Surgery Name: *

Street Address: *

Suburb: *

State: *

Postcode: *

Phone: *

How long have you been with this Doctor: *

Beneficiaries

Name: *

Relationship: *

Date of Birth (day): * Date of Birth (month) * Date of Birth (year) *

Percent of Benefit: *

Name:

Relationship:

Date of Birth (day): Date of Birth (month) Date of Birth (year)

Percent of Benefit:

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Health Questionnaire

Life Insurance Details

Insurance Product

Occupation

Height/Weight

Smoking

Alcohol

Travel

Hazardous Pursuits

Existing or Pending Cover

Family History

Medical History

Females Only

Other Medical

Doctor Details

Beneficiaries

Contact Us

CPA Practitioner

Services

Online Forms

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Health Questionnaire

Life Insurance Details

Insurance Product

Occupation

Height/Weight

Smoking

Alcohol

Travel

Hazardous Pursuits

Existing or Pending Cover

Family History

Medical History

Females Only

Other Medical

Doctor Details

Beneficiaries

Contact Us

CPA Practitioner

Services