Insurance Pre-Assessment - 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 (please specify)

If other, please specify(Required)

State(Required)

Family History

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

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)

This field is hidden when viewing the form

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)

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 use drugs?(Required)

Yes

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

Do you participate in high risk activities?(Required)

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)