Insurance Pre-Assessment Copy - Whitsunday Wealth

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Important Information

Before you start, please read the following important information:

1. Duty of Disclosure: It's important to provide accurate and complete information. Misrepresentation or non-disclosure can lead to your insurance cover being cancelled or claims being denied. Your adviser will rely on the information you provide here.

2. Privacy: Unless we discuss it with you separately, the information you provide here will be passed on to your prospective insurers exactly as you provide it.

3. Accuracy: Ensure all details are accurate and up-to-date. Incorrect information can affect your insurance coverage.

By proceeding, you agree to these terms and confirm that the information you provide is true and correct to the best of your knowledge.

Personal Information

First name(Required)

Surname(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Gender(Required)

Male

Female

Other

If other, please specify(Required)

State(Required)

Family History

Do you have any major illnesses in your family history?(Required)

Only your immediate family history is considered here. E.g., Parents, Siblings.

Yes

Relationship to you(Required)

Parent

Sibling

Both

Select the applicable category for your parent's condition(Required)

Cancer

Heart disease

Diabetes

Auto-immune disease

Neurological disorder

Respiratory disorder

Other

Please provide details.(Required)

Select your parent's specific type of cancer(Required)

Breast cancer

Prostate cancer

Lung cancer

Colon cancer

Other cancer

Select your parent's specific heart disease(Required)

Heart attack

Stroke

Other heart disease

Select your parent's specific type of diabetes(Required)

Type 1 Diabetes

Type 2 Diabetes

Select your parent's specific auto-immune disease(Required)

Rheumatoid arthritis

Lupus

Multiple sclerosis

Other auto-immune disease

Select your parent's specific neurological disorder(Required)

Epilepsy

Parkinson's disease

Other neurological disorder

Select your parent's specific respiratory disorder(Required)

Asthma

COPD

Sleep Apnoea

Other respiratory disorder

Please provide details.(Required)

What age was your parent diagnosed with cancer?(Required)

What age was your parent diagnosed with heart disease?(Required)

What age was your parent diagnosed with diabetes?(Required)

What age was your parent diagnosed with an auto-immune disease?(Required)

What age was your parent diagnosed with a neurological disorder?(Required)

What age was your parent diagnosed with a respiratory disorder?(Required)

Has this illness/these illnesses resulted in death?(Required)

Yes

Please provide details.(Required)

Select the applicable category for your sibling's condition(Required)

Cancer

Heart disease

Diabetes

Auto-immune disease

Neurological disorder

Respiratory disorder

Other

Please provide details.(Required)

Select your sibling's specific type of cancer(Required)

Breast cancer

Prostate cancer

Lung cancer

Colon cancer

Other cancer

Select your sibling's specific heart disease(Required)

Heart attack

Stroke

Other heart disease

Select your sibling's specific type of diabetes(Required)

Type 1 Diabetes

Type 2 Diabetes

Select your sibling's specific auto-immune disease(Required)

Rheumatoid arthritis

Lupus

Multiple sclerosis

Other auto-immune disease

Select your sibling's specific neurological disorder(Required)

Epilepsy

Parkinson's disease

Other neurological disorder

Select your sibling's specific respiratory disorder(Required)

Asthma

COPD

Sleep Apnoea

Other respiratory disorder

Please provide details.(Required)

What age your sibling diagnosed with cancer?(Required)

What age your sibling diagnosed with heart disease?(Required)

What age your sibling diagnosed with diabetes?(Required)

What age was your sibling diagnosed with an auto-immune disease?(Required)

What age was your sibling diagnosed with a neurological disorder?(Required)

What age was your sibling diagnosed with a respiratory disorder?(Required)

Has this illness/these illnesses resulted in death?(Required)

Yes

Please provide details.(Required)

Your Health

Height (cm)(Required)

Weight (kg)(Required)

Body Mass Index (BMI)

Do you have any past or present health conditions?(Required)

Yes

Select the applicable category for your past or present condition.(Required)

Cancer

Heart disease

Diabetes

Auto-immune disease

Neurological disorder

Respiratory disorder

Other

Please provide details.(Required)

Select your specific type of cancer(Required)

Breast cancer

Prostate cancer

Lung cancer

Colon cancer

Other cancer

Select your specific heart disease(Required)

Heart attack

Stroke

Other heart disease

Select your specific type of diabetes(Required)

Type 1 Diabetes

Type 2 Diabetes

Select your specific auto-immune disease(Required)

Rheumatoid arthritis

Lupus

Multiple sclerosis

Other auto-immune disease

Select your specific neurological disorder(Required)

Epilepsy

Parkinson's disease

Other neurological disorder

Select your specific respiratory disorder(Required)

Asthma

COPD

Sleep Apnoea

Other respiratory disorder

Please provide details.(Required)

What age were you diagnosed with cancer?(Required)

What age were you diagnosed with heart disease?(Required)

What age were you diagnosed with diabetes?(Required)

What age were you diagnosed with an auto-immune disorder?(Required)

What age were you diagnosed with a neurological disorder?(Required)

What age were you diagnosed with a respiratory disorder?(Required)

Date of Diagnosis(Required)

Day

Month

Year

Treatment details(Required)

Current symptoms(Required)

Time off work(Required)

The number of days you have had off work due to your condition

Please enter a number from 0 to 9999.

Recovery Status

Fully recovered

Partially recovered

Ongoing treatment

Chronic ongoing

Do you have any past surgeries or hospitalisations not already detailed above?(Required)

Yes

Please provide the approximate length of stay.(Required)

Overnight

3-5 days

6-10 days

11-14 days

15-20 days

21-30 days

31-45 days

46-60 days

61-90 days

> 90 days

Please provide any other details about your stay.(Required)

Do you currently, or have you recently, experienced any of the following health factors:(Required)

High Cholesterol

High Blood Pressure

Low Blood Pressure

Pre-diabetes

Thyroid Issues (e.g., hypothyroidism, hyperthyroidism)

Anemia or Low Iron Levels

Vitamin Deficiencies (e.g., Vitamin D, B12)

Sleep Apnea

Heart Murmur or Arrhythmia

History of Migraines

Digestive Issues (e.g., acid reflux, IBS)

Allergies (e.g., seasonal, food, medication)

Recent Weight Changes (gain or loss within the last 6 months)

Frequent Joint Pain or Arthritis

Asthma or Breathing Difficulties

Mental Health Challenges (e.g., anxiety, depression)

Other health factors

No other health factors

For your High Cholesterol, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your High Blood Pressure, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Low Blood Pressure, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Pre-diabetes, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Thyroid Issues, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Anemia or Low Iron Levels, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Vitamin Deficiencies, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Sleep Apnea, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Heart Murmur or Arrhythmia, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Migraines, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Digestive Issues, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Allergies, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Recent Weight Changes, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Frequent Joint Pain or Arthritis, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Asthma or Breathing Difficulties, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your Mental Health Challenges, please advise any medication or other steps you presently take to manage this health factor:(Required)

For your other health factors, please advise any medication or other steps you presently take to manage this health factor:(Required)

Have you had any notable injuries?(Required)

Back Injury

Neck Injury

Shoulder Injury

Joint Injury

Internal Injury

Other Injury

No notable injuries

Please provide details of your injury.(Required)

Did you/are you receiving specialist treatment for your injury? (e.g. Chiropractic, Physiotherapy)(Required)

Yes

Please provide details of your treatment.(Required)

Recovery Status(Required)

Fully recovered

Partially recovered

Ongoing treatment

Chronic ongoing

Lifestyle

What is your smoker status (includes vaping)(Required)

Non-smoker

Current smoker

Ceased smoking in the last twelve months

Ceased smoking more than twelve months ago

Never regularly smoked

How often do you smoke?(Required)

Daily

Weekly

Occasionally

Do you have a history of drug use?(Required)

Yes

Please provide details (name/type, frequency, date of last use).(Required)

Do you participate in high risk activities?(Required)

E.g., Scuba diving, BASE jumping, hang gliding, race car driving, flying a plane, horseback riding, bungee jumping, parasailing, off-roading..

Yes

Please provide details (type of activity, frequency, professional engagement).(Required)

Occupation

What is your employment status?(Required)

Employed full-time

Employed part-time

Casual

Contractor

Self-employed

Unemployed

Retired

Specify your occupation.(Required)

What is your business structure?(Required)

Sole trader

Partnership

Company (sole director)

Company (joint director)

Other

Please provide details.(Required)

What industry do you work in?(Required)

Do you work in any of the following environments?

Offshore

At heights

Underground

Work site

Handling hazardous materials

Other non-standard environment (please specify)

I do not work in any non-standard environment

Please provide your safety and health details.(Required)

Please provide details.(Required)

Do you have a secondary occupation?

Yes

Please provide details.(Required)

Financial Information

Current Employment/Self-Employment Details(Required)

Income Type

Annual amount (before tax)

Business Ownership Details(Required)

Number of years in current self-employment structure?(Required)

Please enter a number from 1 to 100.

Is your self-employed work similar to your previous work?(Required)