Insurance Details

Sex

MaleFemaleOther

Occupation

Length of time in your occupation

How many months per year do you work in your current principal occupation

How many hours per week do you work in your current principal occupation

How long are you likely to continue to receive an income due to sick leave pay (days)?

Pastimes

Do you currently engage in, or intend to engage in, any of the following pursuits, pastimes or activities?

Any type of football (including, but not limited to, rugby union, rugby league, touch football, soccer, Australian football);
Motor sports (including, but not limited to, trail bike riding);
Recreational activities involving heights (including, but not limited to, rock climbing, abseiling, mountaineering, parachuting, hang-gliding);
Combat sports (including, but not limited to, boxing, martial arts, mixed martial arts);
Underwater recreational activities (including, but not limited to, scuba diving);
Water sports (including, but not limited to, canyoning, water skiing);
Underground activities (including, but not limited to, caving);
Flying (other than as a fare paying passenger on a regular airline service);
Skiing, snowboarding or skating; orany other competitive sport.

YesNo

Please Provide Details Of Activity

Frequency Per Month

Competitive Nature (recreational, amateur, professional)

Family History

Have any of your blood related parents, brothers or sisters (living or deceased) been diagnosed with, or suffered from, any of the following conditions?

Cystic fibrosis
Familial polyposis of bowel (FAP)
Huntington's disease
Multiple Sclerosis
Muscular dystrophy
Motor neurone disease
Parkinson's disease
Polycystic kidney disease

YesNo

Have any of your blood related parents, brothers or sisters (living or deceased) been diagnosed before the age of 60 with anyof the following conditions?

Alzheimer's disease or any other form of dementia
Bowel cancer
Breast cancer
Cardiomyopathy
Diabetes
Heart attack, coronary artery bypass or had a stent
Melanoma
Ovarian cancer
Prostate cancer
Stroke
Any other cancer
Any other hereditary or familial disorder

YesNo

If you have answered Yes to either of the above questions please provide details below:

Relationship (do not state name)

Condition or Disorder

Age diagnosed

Age at death (if applicable)

Smoking and Alcohol

Have you smoked tobacco, cigars or a pipe, or any other substance within the past 12 months or used a product containing nicotine in the last 3 months?

YesNo

Type: Cigarette, pipe, cigar or other (please specify)

Quantity (per day)

Do you consume alcohol?

YesNo

Type

Quantity (please specify per day or per week)

Have you ever been advised by a health service provider to give up or reduce the amount of your smoking or alcohol consumption due to medical reasons?

YesNo

Please provide details including the reason for the advice, when the advice was given, and list any conditions that resulted from your smoking and/or drinking:

Height and Weight

Height (cm or ft, in)

Weight (kg or st, lbs)

Has your weight changed more than 10kg in the past 12 months (excluding pregnancy)?

YesNo

Please provide details:

Health Details

Have you ever had, or have you ever been told you have had, any of the conditions listed in below:

Asthma or chronic bronchitis?

YesNo

Have you had any symptoms or treatment in the last five years?

YesNo

Have you had an attack of asthma or chronic bronchitis within the last two years?

YesNo

Have you had more than five days off work or been on limited duties within the last two years due to asthma or chronic bronchitis?

YesNo

In the last five years, have you been admitted to hospital, or required emergency treatment, including the use of systemic steroids for asthma or chronic bronchitis?

YesNo

Do you require the use of non-steroidal inhalers on a daily or regular basis?

YesNo

Back or neck pain, strain or disorder?

YesNo

Has a back or neck disorder been diagnosed as anything other than muscular aches, strains, pains or spasms?

YesNo

In the last 2 years have you experienced symptoms, received treatment (eg physiotherapy, chiropractic, osteopathy or prescription medications), or attended your health service provider for a back or neck disorder?

YesNo

Have you ever attended, or do you plan to attend, a neurologist or orthopaedic surgeon, or undergone (or plan to have) an X-Ray, MRI, or CT scan for a back or neck disorder?

YesNo

Have you ever had, or has it ever been recommended that you have, surgery to treat a back or neck disorder?

YesNo

Skin lesion (including, but not limited to, cyst, mole, growth)

YesNo

Have you noticed or become aware of any change in size, shape, or colour of any skin lesion, whether or not you have consulted a doctor?

YesNo

Have you had more than one lesion/cyst?

YesNo

Has any lesion/cyst been confirmed by a specialist consultant to be melanoma, basal cell carcinoma, squamous cell carcinoma or malignant (cancerous)?

YesNo

Has any lesion been removed by a procedure other than being burnt/frozen off?

YesNo

Were you advised to have any further tests (excluding genetic testing), treatments, checks or follow-ups for any lesion?

YesNo

Gout

YesNo

Have you had any symptoms, treatment or time off work in the last three years due to your gout?

YesNo

Any vision impairment of eye disorder

YesNo

Have you had any treatment for your vision impairment or eye disorder (excluding the use of glasses, contact lenses or successful corrective laser eye surgery (LASIK) to treat long or short sightedness or astigmatism)?

YesNo

Is your vision impairment or eye disorder anything other than long or short sightedness or astigmatism?

YesNo

Joint or muscle disorder (including pain, strain, sprain, tear, dislocation or facture)

YesNo

Have you ever had any joint or muscle disorder(s) that was anything other than a strain, sprain or fracture?

YesNo

Have you ever had any joint or muscle disorder(s) that required surgical repair or reconstruction?

YesNo

Have you had any symptoms from, or required any treatment for, any joint or muscle disorder(s) in the last two years?

YesNo

Have you ever had more than five days off work or been on limited duties due to any joint or muscle disorder(s)?

YesNo

Mental or nervous condition including anxiety, stress and depression

YesNo

Was a mental health or nervous condition anything other than a single episode of anxiety, stress or depression (excluding severe and manic depression)?

YesNo

In the last 5 years, have you required a total of 5 consecutive days off work, or 5 days where you were unable to perform your usual activities due to a mental health or nervous condition?

YesNo

Have you ever been prescribed Lithium, Seroquel, Endep, Placil or Epilim, or have you received any form of treatment in the last 12 months for a mental health or nervous condition?

YesNo

Have you ever been admitted to hospital, or have you ever considered or attempted suicide due to a mental health or nervous condition?

YesNo

Was a mental health or nervous condition first diagnosed, was treatment first prescribed, or were symptoms first present in the last 12 months

YesNo

If you have answered No to all of the questions above please outline your degree of recovery, any ongoing symptoms, and any plans to consult a health service provider for a mental health or nervous condition below.

Have you ever had, or been told you have had, any of the following symptoms or conditions that have not already been disclosed above?

Blood disorder (including, but not limited to, anaemia, haemophilia, blood transfusion, leukaemia, lymphoma)

YesNo

High Blood Pressure or High Cholesterol

YesNo

Heart or cardiovascular condition (including, but not limited to, chest pain, angina, rheumatic fever, heart complaint, blood vessel conditions)

YesNo

Cancer, tumour, growth or lump (excluding skin lesions)

YesNo

Kidney, bladder or prostate disorder (including, but not limited to, kidney stones, urinary tract infection, raised or rising PSA blood test result, prostate enlargement or inflammation)

YesNo

Bowel, colon, gastro-intestinal disorder or reflux condition (including, but not limited to, hernia, ulcers - non mouth, irritable bowel syndrome, colitis, haemorrhoids)

YesNo

Arthritis, Repetitive Strain Injury (RSI), Chronic Fatigue Syndrome (CFS), Occupational Overuse Syndrome (OOS), Tenosynovitis, Chronic Pain Syndrome, or Fibromyalgia

YesNo

Stroke, Paralysis or nerve disorder (including, but not limited to, Bell's Palsy)

YesNo

Epilepsy or fainting attacks

YesNo

Any neurological disorder (including, but not limited to, headaches, dizziness, Multiple Sclerosis, dementia, meningitis, head injury, motor neurone disease, muscular dystrophy, Parkinson's disease)

YesNo

Liver or gall bladder disorder (including, but not limited to, hepatitis, jaundice, haemochromatosis)

YesNo

Diabetes, thyroid or glandular disorder (including, but not limited to, low/high blood sugar, pancreatic conditions)

YesNo

Respiratory or lung disorders (including, but not limited to, bronchitis, pneumonia, emphysema or tuberculosis)

YesNo

Sleep apnoea or any sleep disorder

YesNo

Ear, or speech disorder or any other physical impairment

YesNo

Skin conditions or varicose veins (including, but not limited to, psoriasis, eczema, dermatitis)

YesNo

Any other illness, injury or condition

YesNo

Other than already disclosed, have you in the last three years:

Been prescribed or taken any medication, drug or tablet for at least 4 weeks in any 12 month period (other than antibiotics, contraception or hair loss treatment)?

YesNo

Been referred to a medical specialist?

YesNo

Had a surgical procedure?

YesNo

Been diagnosed with a medical condition or disorder?

YesNo

Had an investigation, test or consultation that resulted in advice to undergo further medical investigations, tests or consultations (excluding genetic testing)?

YesNo

Have you used (by mouth, inhalation or injection) any recreational drugs or substances?

YesNo

Are you contemplating, or have you been told to seek any advice, tests, investigations or treatments not already disclosed (excluding genetic testing)?

YesNo

Have you ever had a genetic test or have you consented to having a genetic test?

YesNo

Have you received or do you expect to receive a result from your genetic test?

YesNo

Please provide full details of the genetic test including the result (if available) and any further treatment, investigation, test, consultation or operation you have had or intend to have.

Please advise the reason you have not received and do not expect to receive a result from your genetic test.

Are you infected with, or do you have an increased risk of exposure to, the Human Immunodeficiency Virus (HIV),Hepatitis B, or Hepatitis C?

YesNo

Have you ever had any gynaecological disorder (eg endometriosis, cervical cancer) or abnormal results from a PAP smear test?

YesNo

Have you ever had breast lumps or an abnormal result from a breast examination?

YesNo

Are you currently pregnant?

YesNo

Have you ever had any pregnancy complications (please do not include elective caesarean or a miscarriage within the first 15 weeks of pregnancy)?

YesNo

Are you in your final 10 weeks of pregnancy?

YesNo

Will you be returning to your usual occupation, duties, and hours after maternity leave?

YesNo

For any of the above items where you have marked an answer Yes, please provide full details (including date of first symptoms, date of last symptom, degree of recovery, details of investigations and treatment, any ongoing treatment/follow up, and the name and contact details of any health service provider consulted)

Duty of Disclosure

You have a duty, under the Insurance Contracts Act 1984, to inform an insurer of every matter that you know, or could reasonably be expected to know, is relevant to the decision whether to insure you and, if so, on what terms.

The “Duty of Disclosure” applies before you enter into, extend, vary or reinstate a Policy, and applies until the time when the insurer issue a policy schedule, membership certificate or other written confirmation of the issue, extension, variation or reinstatement.

If any information provided changes (including any change to your health, occupation or pastimes) before the insurer sends the policy schedule, membership certificate or other written confirmation of cover to you, you must tell the insurer.

The duty does not require disclosure of any matter:

that diminishes the risk to be undertaken by an insurer;
that is of common knowledge;
that we know or, in the ordinary course of our business, ought to know; or
as to which compliance with your duty is waived by us.

Non-disclosure

If you fail to comply with your duty and the Policy would not have been entered into if the failure had not occurred:

the Policy may be varied to reduce the sum insured or to reflect the terms that would have applied if you had complied with your duty; or
the Policy may be treated as never having existed if your non-disclosure was fraudulent or, if it is within 3 years of entering into the Policy, the insurer would not have been prepared to enter into the contract of life insurance on any terms.

I have read and acknowledge my Duty of Disclosure *