Life Insurance Pre-Assessment Form
Answer a few questions to help us assess your coverage needs.
Full Name
*
First Name
Last Name
Date of Birth
*
 .
Day
 .
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Gender
*
Male
Female
Email Address
*
example@example.com
What is your smoking status
*
Non-Smoker (Lifetime)
smoker (including Vaping)
non-smoker (12 months +)
Used nicotine replacement therapies in the last 12 months
Have you ever been diagnosed with any of the folliwing?
*
Diabetes
Cancer
Epilepsy
Auto-immune condition
High blood pressure
High Cholesterol
Sleep Apnoea
Heart Condition
Digestive disorder e.g Ulcerative colitis, Crohns disease
Respiratory condition (excluding childhood asthma)
Problems with your eyes (not corrected with glasses)
Hearing problems
None of the above
Other
Tests & investigations: Have you ever experienced any of the following?*
*
Had investigative tests with a finding or abnormal result e.g. blood test, ultrasound, MRI or Xray (even if since resolved)
Been referred to a specialist (whether completed or outstanding)
Undergone or recommended to have any type of surgery (excludes cosmetic surgery)
None of the above
Ladies only:
Currently Pregnant
Abnormal Pap Smear / Mammogram result
None of the above
Joints & Muscles: Have you ever been treated for or been diagnosed with any of the following?*
*
Seen a Physio, Chiro or Osteopath
Fractured any bones (excluding in childhood)
Injured a ligament or tendon
Been diagnosed with any form of athritis
Experienced a joint injury or joint pain e.g whiplash, bulging disc etc
None of the above
Mental Health: Have you ever been diagnosed with or received any of the following?*
*
Depression
Stress / Anxiety
Psychologist / Counsellor visit
Mental Health plan issued by GP
ADHD
None of the above
If you answered yes to any of the questions please provide details.
E.g. approx date, duration, general circumstances and outcome.
Height (in cm or inches)
*
Weight (in kg or lbs)
*
Occupation
Prescription medication: Excluding contraceptives or antibiotics, have you ever been prescribed medication?
Yes
No
Family History: Have any of your parent or siblings been diagnosed with any of the following conditions*
*
Heart Condition
Cancer
Diabetes
Stroke
Major Psychiatric conditions e.g Bipolar or Schizophrenia
Any other hereditary disorders
None of the above
Do you currently participate in any of these pastimes?
*
Motorsports
Flying Aircraft
Scuba Diving
Outdoor Rock Climbing
Football (Soccer, Rugby, etc)
Mountain Bike Riding
A sport where you receive a payment or match fee
Sailing offshore
Have you ever made a claim for Disablement Benefits?
*
Workers Compensation
Centrelink Disability Support payments
Income Protection
Trauma
Total and Permanent Disablement
None of the above
Is there anything else that you feel may be relevant?
Have you ever been declined insurance or had a medical loading or exclusion applied?
*
Yes
No
Submit Pre-Assessment
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