Life Insurance - Pre-Assessment Questionnaire This form allows us to obtain insurance quotes accurately on your behalf Step 1 of 5 20% Name* First Last Date* DD slash MM slash YYYY Current Age*Gender* Male Female Employment HistoryOccupation*Duration in role*Annual Income*What percentage of your daily duties involve a manual component?*List manual duties*Does your role include any domestic travel or field work?* Yes No If yes, please provide details on travel (i.e. duties, frequency, locations)Do you perform any hazardous activities? (i.e. working at heights, handling explosives, working underground)* Yes No If yes, please provide details (i.e. frequency, duties)Employment Status* Casual Part Time Full Time Contractor Non-working Do you intend to make any changes to your employer status within the next 12 months?* Yes No If yes, please provide details (i.e. become casual, change occupation)Do you participate in any sports or pasttimes?* Yes No If yes, please provide details (i.e. activity, frequency, competitive or non-competitive) Medical HistoryHeight*Weight*Have you lost >10kg in the last 12 months?* Yes No Have you smoked tobacco, used nicotine-based substances or taken illicit drugs in the last 12 months?* Yes No If yes, please provide details (i.e. type, frequency, last used)Have any of your biological immediate family suffered any of the following conditions before the age of 65?* Heart disease, heart attack or stroke Multiple Sclerosis, Parkinson's disease or Alzheimer's Muscular dystrophy, Huntington's or Motor Neurone disease Polycystic kidney disease Breast or ovarian cancer Mental health condition Cardiomyopathy Bowel cancer Melanoma Diabetes Other Not Applicable If yes to any of the above, please provide details of family member, age at time of diagnosis, condition (if cancer: type, stage, location)Have you ever had/have, or sought advice or treatment from a health professional for any of the following* Stress, anxiety, depression or mental health disorder Skin cancer, tumour, skin lesion, mole or cyst Back or neck strain/pain, sciatica, spondylitis or any back/neck problem Bone/joint fracture, muscle, ligament, tendon injury, gout or arthritis* Asthma / respiratory conditions Disease/condition of eye or ears High blood pressure High cholesterol Skin conditions HIV, Hep B or C Diabetes Heart condition Thyroid condition Blood condition Not Applicable Have you ever had or been advised to have treatment for: Any breast lump or any abnormal mammogram or breast ultrasound Any abnormal cervical smear (pap smear) test including the detection of HPV or any abnormality of the ovaries Abnormal vaginal bleeding within the last 12 months Condition DetailsConditionDate of diagnosis DD slash MM slash YYYY Degree of recoveryList of symptomsFrequency of symptomsDate of first & last symptomsHave you taken time off work (note days)?List of treatmentsFrequency of treatmentDate of first & last treatment Medical Advice and Additional InformationDo you intend to seek any medical advice, test or investigation or treatment (including surgery)?* Yes No If yes, please provide details (i.e condition, date of treatment/surgery)Additional information (i.e. existing cover, loadings/exclusions or current medications)*
