Pre-Insurance Advice Questionnaire

1 Personal Details
2 Insurance & Health
Personal Details
Gender:
What is your citizenship status?
Insrurance & Health
Have you smoked or used any nicotine containing products in the last 12 months?
Have you had an insurance application (for IP, Life, TPD, or Trauma) declined?
Have you received or made a claim for any sickness, injury, or disabilities benefits?
Have any of your immediate family been diagnosed with any of these conditions?
Cystic Fibrosis
Familial Polyposis of Bowel
Huntington’s Disease
Multiple Sclerosis
Polycystic Kidney Disease
Muscular Dystrophy
Multiple Sclerosis
Motor Neuron Disease
Parkinson’s Disease
Have any of your immediate family been diagnosed with the following before the age of 60?
Alzheimer’s or any form of dementia
Diabetes
Heart Attack, had a Bypass or a stent
High Cholesterol
High Blood Pressure
Stroke
Cancers including melanoma
Do you take part in any hazardous pursuits or past times? (including any contact sports (boxing, MMA), motorsports, sports involving heights (bouldering, rock climbing, aerials), scuba diving etc)
Are you currently pregnant?
Have you been diagnosed with any of these conditions?
Diabetes
Epilepsy
Autoimmune conditions
High Cholesterol
Optical or Auditory conditions
Sleep Apnoea
Heart conditions
Respiratory Conditions
Neurological Conditions
Lesions or abnormal lumps
Cancer
Arthritis
Osteoporosis
Have you asked for or received advice, counselling or medication for your mental health or mental wellbeing from a health professional (GP, counsellor, psychologist, or psychiatrist)?
Have you experienced any back or neck pain in the last 5 years? Or have you ever been diagnosed with scoliosis, any disc issues, spine fractures, or suffered from a traumatic spine injury?
Have you suffered from any other bone, muscle, or joint injury in the last 5 years?
Have you ever been referred to a specialist? (not including for pregnancy or fertility)
Are you waiting or are overdue for any test, consultations, surgery, or are currently being investigated for any conditions, or have you received any specialist referrals that you have not yet completed?
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