Insurance Health Questionaire

Thank you for completing this short health questionaire.
Please answer the questions and press “send” at the bottom

*This should only take about 5-10 minutes

*Many questions are simple yes/no answers

*Some Questions may not apply to you (eg gender specific questions)- leave them blank

Section 1 Life to be Insured details

Title
 Mr Mrs Miss Dr. Other

First Name

Middle Name

Surname

Gender
 Male Female

Date of Birth (DD/MM/YYYY)

Residential address (Your residential address cannot be a Post Office (PO ) Box)

Unit number

Street number

Street name

Suburb

Postcode

State

Country

Section 2 Residency and Travel

Are you a permanent resident of Australia?
 Yes No

How Long have you lived in Australia?

Last Country of Residence

How long did you live there?

Visa Type

Visa expiry (DD/MM/YYYY)

Have you applied for permanent residency?
 Yes No

Please Provide details:

Reason for not applying:

Do you have any intention of travelling or residing outside Australia?
 Yes No

If yes please complete the table below(if no goto section 3 below):

Date(s) of Departure(s)

Duration of stay(s)

Destination(s)

Purpose of stay(s) (eg holiday, business, residing)

Section 3 Occupation and Financial

What is your employment status?

 Self-employed(You directly own all or part of a business) Employee (You do not directly own all or part of a business Homemaker, Student, Unemployed or retired - Go to Section 4

Please provide details of your primary occupation and any professional or trade qualifications

a. Primary occupation

b. Industry

c. Name of employer or trading name

d Street address of employer or business

Postcode

e Professional or trade qualifications

Please provide full details of your occupational duties in the table below, including a percentage breakdown of the type of work performed:

What are your Sedentary/Administration Duties?

Percentage of time in Sedentary/Administration Duties
percent

What are your Light manual work Duties?

Percentage of time in Light Manual work duties
percent

What are your Heavy manual work Duties?

Percentage of time in Heavy Manual Work
percent

Total percentage(should equal 100%)

Heights over 10 metres, any (percentage)
 Yes No

Underground or offshore (percentage)
 Yes No

Use of explosives
 Yes No

Other (please specify)

What are the specific duties you perform in your job?

Are you applying for Total and Permanent Disability, Income Protection or Business Expenses insurance?
 Yes No

Are you self employed or do you own all or part of the business in which you are employed?
 Yes No

If you answered yes, please complete questions a to e below, if you answered no, go straight to f)

a) Have you been self employed in your current business for more than 12 months?
 Yes No

b) On what basis do you operate your business?
 Sole Trader Company Partnership Trust

c) What percentage interest shareholding do you have in the business?

d) How many employees (other than yourself) do you have?

e) Has your business had a net operating loss in either of the last two years?
 Yes No

If yes, please provide last two years’ financial accounts for all entries

f)Have you been working in your occupation, trade or profession for five or more continuous years?
 Yes No

Please provide details of all positions you have held over the last five years

From

To

Occupation

Employer Name

Over the next 12 months, do you intend to change your occupation or become self-employed?
 Yes No

•Change your occupational duties or work hours?
 Yes No

•Take extended leave?
 Yes No

Please provide details below

How many hours per week do you work in your primary occupation?

Do you work at your home for more than 20% of your working hours?
 Yes No

How many hours per week do you work from home?

What were your Earnings before tax for the last 12 months from your primary occupation? (Do not include investment income)

I declare that my Earnings as stated above are before tax, after the deduction of business expenses, over the last 12 months is from primary occupation only and do not include income from a second occupation; and is within 15% of my Earnings for the 12 months immediately prior to the above period.
 Yes No

Section 4 – Other Insurances

Are you covered by, or are you applying for, any other life, disability, critical illness, income protection, salary continuance or business expenses insurance with any company, (other than this application), including benefits under superannuation or insurance benefits provided by your employer?
 Yes No

Please provide details below

Company

Benefit type

Date started

Benefit amount

Waiting Period

Benefit Periods

Policy number

To be replaced
 Yes No

Section 5 Height and Weight Details

21 What is your height?

What is your weight?

22 Have you undergone surgery to reduce your weight in the last five years
 Yes No

Please provide details, including date of surgery

Section 6 Habits and Lifestyle

23 Have you smoked tobacco or any other substance or used any nicotine-containing product in the last 12 months?
 Yes No

If yes what type?
 Cigarette or Cigars or Pipe Gum/Patch Other

Quantity

per
 day week month year

24 Do you drink alcohol?
 Yes No

How much do you consume on average?

Quantity

per
 day week month year

(Standard drink = 1 nip (30ml) spirits, 100 ml wine, 10 oz / 285 ml beer)

25 Have you ever been advised by a health professional or attended a support group to reduce or cease your alcohol intake?
 Yes No

Please provide details

26 In the last five years, have you used (by mouth, inhalation or injection) any drug not prescribed for you by a doctor?
 Yes No

Please provide details

27 Have you ever received advice, counselling or treatment for drug dependence?
 Yes No

Please provide details

Section 7 Sports and Pastimes

28 Do you now or do you intend to take part in any of the following activities? Please tick all that apply and provide details below

Diving
 Yes No

Motor car, motor cycle or motor boat racing
 Yes No

Flying as a pilot or crew in an aircraft
 Yes No

Football (all codes)
 Yes No

Hang- gliding, paragliding, skydiving, pursuits
 Yes No

Section 8 Family History

29 Have any of your (immediate blood relatives ie Father, Mother brothers or sisters) suffered from any of the following conditions? (If yes please supply details below)
 Yes No

Heart disease or stroke
 Yes No

Diabetes
 Yes No

Muscular dystrophy
 Yes No

Breast or ovarian cancer
 Yes No

Multiple Sclerosis
 Yes No

Polycystic Kidney Disease (PCKD)
 Yes No

Melanoma
 Yes No

Parkinson’s disease
 Yes No

Huntington’s disease
 Yes No

Bowel cancer or Familial
 Yes No

Rheumatoid arthritis
 Yes No

Motor neurone disease
 Yes No

Polyposis (FAP)
 Yes No

Any other cancer not other wise listed(specify type and site
 Yes No

Haemochromatosis
 Yes No

Any Other hereditary disorder
 Yes No

(If yes please supply details below)

Family member ie father/mother/brother/sister

Condition

if cancer, type and site

Age when condition began

Family member ie father/mother/brother/sister

Condition

if cancer, type and site

Age when condition began

Section 9 Health A- Supplementary underwriting Questionnaires

30 Have you ever had, or been told you had, or ever sought advice or treatment from a doctor, counsellor or other health professional for any of other following: (Please tick all that apply below and if yes, please supply details including dates, doctor/hospital, treatment and drugs, and degree of recovery)

•Stress, anxiety, depression, post traumatic stress disorder(PTSD) or any other mental health disorder
 Yes No

•High blood pressure
 Yes No

•High cholesterol
 Yes No

•Asthma
 Yes No

•Skin cancer, tumour, skin lesion, mole or cyst
 Yes No

•Back or neck strain/sprain or pain, sciatica, whiplash, spondylitis, fracture or any back, neck or spinal problem
 Yes No

•Any bone/joint fractures, muscle, ligament or tendon injuries, tenosynovitis, gout, arthritis or osteoporosis
 Yes No

A) Skin conditions or any of the following: Rash, Eczema, Psoriasis, Dermatitis or any allergy affecting the skin
 Yes No

Any other skin condition or disorder of the skin
 Yes No

B) Blood conditions or any of the following: Haemochromatosis, Haemophiliaon, Anaemia
 Yes No

Any other blood condition not previously mentioned
 Yes No

C) Any disease or disorder of the eyes or ears or any of the following:
 Yes No

Any type of eye condition
 Yes No

Any type of ear or hearing condition including Meniere’s Disease, labyrinthitis,
 Yes No

tinnitus or dizziness
 Yes No

D) Blood Vessels, cardiovascular, heart conditions or any of the following:
 Yes No

Rheumatic fever, heart murmur, angina, heart attack or other type of heart valve condition
 Yes No

Varicose veins, bloods vessel or a blood clotting condition/disorder
 Yes No

Chest pain
 Yes No

Any other type of heart condition/disorder
 Yes No

E) Respiratory conditions or any of the following:
 Yes No

Bronchitis
 Yes No

Hayfever
 Yes No

Sleep apnoea
 Yes No

Any other lung or respiratory condition
 Yes No

F) Bowel, colon, liver, gastro intestinal conditions or any of the following:
 Yes No

Liver condition
 Yes No

Hepatitis
 Yes No

Irritable bowel disease
 Yes No

Bleeding from the bowel or haemorrhoids
 Yes No

Gastroesphagael reflux (GORD), hiatus hernia, peptic or gastric ulcers
 Yes No

Colitis, Crohn’s disease, ulcerative colitis or polyps
 Yes No

Gall bladder condition
 Yes No

Any other bowel, colon or general gastro intestinal condition not previously mentioned
 Yes No

G) Diabetes, thyroid conditions or any of the following:
 Yes No

Sugar in your urine, low or high blood sugar,
 Yes No

diabetes or any pancreatic condition
 Yes No

Thyroid condition
 Yes No

H) Neurological, circulatory conditions or any of the following:
 Yes No

Epilepsy or seizures
 Yes No

Stroke/Cerebro-vascular accident (CVA), transient ischaemic attack (TIA), reversible ischaemic
 Yes No

neurological disorder (RIND), brain haemorrhage or other brain condition
 Yes No

Paralysis or multiple sclerosis (MS)
 Yes No

Neuritis or other nerve condition
 Yes No

Fainting or dizziness
 Yes No

Headaches or migraines
 Yes No

I) Cancer or tumour of any kind (benign or malignant) that has not already been disclosed in this application?
 Yes No

Males only:

Kidney condition
 Yes No

Disorder of the reproductive system (Do not include vasectomy)
 Yes No

Bladder condition, urinary tract infection
 Yes No

(UTI) or blood in the urine
 Yes No

Prostate condition
 Yes No

K Females only

Kidney Condition
 Yes No

Bladder condition, urinary tract infection, cystitis or blood in the urine
 Yes No

Disorder of the breast and/or any test or investigation including mammograms or ultrasounds
 Yes No

Abnormal pap smear
 Yes No

Endometriosis
 Yes No

Abnormal menstruation
 Yes No

Any other disorder of the reproductive system (not previously mentioned in this application).Do not include tubal ligation or uncomplicated caesarean sections
 Yes No

Are you currently pregnant?
 Yes No

If yes, Please provide due date (DD//MM/YYYY)

Further information

If you answered ‘Yes’ to any question in Section 9, Please provide details below

Condition 1

Reason or test

Date started

Date of last symptoms

Type of Treatment and any test results

Degree of recovery

Time off work

Name and address of doctor, hospital or health professional consulted

Condition 2

Reason or test

Date started

Date of last symptoms

Type of Treatment and any test results

Degree of recovery

Time off work

Name and address of doctor, hospital or health professional consulted

Section 10 Health C-General

32 Are you carrying the Human Immunodeficiency Virus (HIV) which causes AIDS, antibodies to that virus, or are you suffering from AIDS or any AIDS-related condition?
 Yes No

33 In the last three years, are you aware of any HIV risk situation to which you or any of your sexual partners may have been exposed?
 Yes No

Note: HIV risk situations include but are not limited to: sex with someone you know or suspect to be HIV positive , sex with an intravenous drug user , sex without a condom with a sex worker anal intercourse without a condom (except in a relationship between you and one other person only and neither of you have had sex with anyone else for a least three years).

Section 11 Health D-General

Doctor’s details

34 Do you have a usual doctor?
 Yes No

If yes, please provide full name and address of your usual doctor or medical centre

If no, please provide the name and address of the last doctor you visited

Name of doctor or medical centre

Address

Suburb

Postcode

State

Country

Telephone

Email

35 How long have you been attending this doctor/medical centre?

 years months

When did you last attend?

36 If you have been attending this doctor or medical centre for less than 12 months, please also provide name and address of your previous doctor

When did you last attend?

Other medical conditions

Childhood illnesses such as chicken pox, measles, mumps, tonsillitis, or tonsillectomy,

appendicitis or appendectomy, unless you have not made a complete recovery.

In answering questions 37,38,39 and 40, do not include: Colds, flu or minor viral illness that were short, isolated occurrences or medications for these conditions, or annual check-ups where the results were normal.

37 Have you ever sought advice or treatment from a doctor or other health professional for any illness or injury, or undergone any investigations (eg genetic testing or ECG) not already mentioned in this application
 Yes No

Please provide details in the table below

38 Have you in the last five years taken any drug/tablet, medication or herbal medicines on a regular or ongoing basis not already mentioned in this application?
 Yes No

Please provide details in the below

39 Have you had any blood test in the last 12 months (not previously mentioned)?
 Yes No

Please provide details including the results below

40 Do you now have any other disability, illness, injury or symptom not already mentioned in this application?
 Yes No

Please provide details below

41 Do you contemplate seeking any medical advice, test investigation or treatment (including surgery)?
 Yes No

Please provide details below

If you answered ‘Yes’ to any question numbered 37-41, please provide details below, including results:

Question

Condition

Reason of test

Date started

Date of last symptoms

Type of treatment and any test results

Degree of recovery

Time off work

Name and address of doctor, hospital or health professional consulted

Section 12 Further Information

If you provide further information, please note the question number

the additional information refers to.

Question no.

Further information