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Insurance Health Check

Would you like an insurance quote? Please complete the form below and click ‘submit’ and we’ll get back to you as soon as possible.

Personal Details
Title *
First Name *
Last Name *
Date of birth * / DD / MM YYYY
Email *
What is the best time to contact you? *
If other time, please specify
Preferred phone *
Postcode *
Have you ever been declined insurance in the past? *
If yes, what was the reason why you were knocked back?
Dependants
Do you have any children?
If yes, How many and what are their ages? *
Existing Lump Sum Insurance
Life Insurance
Do you have existing life Insurance?
Insurance Provider
Insured Value
How much do you pay for your existing life insurance cover?
Approximately when was your life insurance cover taken out? / DD / MM YYYY
How much do you have in debt, including your home loan, investment loans, motor vehicle debts, credit cards and personal loans?
Trauma Insurance
Do you have existing trauma Insurance
Insurance Provider
Insured Value
How much do you pay for your existing trauma insurance cover?
Approximately when was your trauma insurance cover taken out?
Total & Permanent Disability (TPD) Insurance
Do you have existing Total & Permanent Disability (TPD) Insurance?
Insurance Provider
Insured Value
How much do you pay for your existing TPD insurance cover?
Approximately when was your TPD insurance cover taken out? / DD / MM YYYY
Existing Ongoing Insurance
Do you have existing income protection Insurance?
Insurance Provider
Insured Value
How much do you pay for your existing income protection cover?
What is your current annual income?
What is your waiting period
What is your benefit payment period
Approximately when was your Income protection insurance cover taken out? / DD / MM YYYY
Physical details

In calculating premium rates and your eligibility for a life policy, there are a number of factors that need to be taken into consideration.
Height
Weight
Are you a smoker?

Select smoker if you smoked within the last 12 months.
What is your occupation?
Are you required to do any physical work?
If yes please specify what physical work you are required to do and how often
Health Details

Not only does your own health influence your eligibility and the price you pay for your insurance, some aspects of your immediate family health history is also taken into account.
Do you take any subscription medications?
If yes, please specify the name of medication, dosage (if known), the condition being treated and the length of time the medication has been taken
Have any of your parents or siblings had cardiovascular decease or cancer
If yes, please explain, including age of onset, diagnosis and death (if applicable)
Have you ever been treated for the following: Aids Alcohol or drugs Alzheimers disease Asthma Cancer Cholesterol Depression Diabetes Heart disease Hypertension Kidney disease Liver disease Mental illness Pulmonary disease Stroke Ulcers Vascular disease Other None
Please select all that apply.
If other, please specify?
If you checked any of the above other than ‘None’, please explain
Occupational details

Another key factor in determining the price you pay for your life insurance and/or income protection is the type of work that you do and your employment status.
What is your employment status
If other, please specify
What is your occupation title?
In what industry do you work?
What qualifications do you hold?
Please explain the nature of your work (your day to day activities)
Other information
Is there anything else you would like to add that was not previously mentioned that you think can affect your insurance premiums or eligibility?
Where did you hear about us?
If employer, association, or other please specify name

Insurance Health Check

Insurance Health Check

Personal Details

Dependants

Existing Lump Sum Insurance

Existing Ongoing Insurance

Physical details

Health Details

Occupational details

Other information