If you have spoken to a broker in our office, note their name here so that this quote can be processed by them as they will know something about you already.

Brokers Name:

First Name

Last Name

Email Address

Phone No. *

Address *

Underwriting Questions

Occupation:

Gender
Please select Male Female

Smoking Status
Please select Smoker Non-Smoker

Height:

Weight (kgs):

Date of birth:

General information

Are you a permanent resident of Australia?
Yes    No

Do you intend working outside of Australia?
Yes    No

Has your business been operating more than 12 months?
Yes    No

In the last 10 years, have YOU received treatment or advice from a Registered Medical Practitioner (including but not limited to a doctor, chiropractor, physiotherapist, psychiatrist or naturopath) in relation to

• Asthma;
• Arthritis or rheumatism;
• Bowel disorder;
• Brain, epilepsy or other disorder of the central nervous system;
• Cancer or tumour;
• Depression, psychological, psychiatric or personality disorder;
• Diabetes - Type 1;
• Diabetes - Type 2;
• Disorders of circulatory system - including heart, arteries;
• Disorder of the digestive systems;
• Disorder of the Head, back, neck or spine;
• Disorder of the musculoskeletal system;
• Disorder of the eyes;
• Disorder of the ears
• Drug or alcohol dependence;
• Hepatitis A & B;
• Hepatitis C
• Hernia or associated condition;
• High blood pressure ;
• High cholesterol;
• HIV, AIDS or AIDS related conditions;
• Kidney, bladder, liver, spleen, or other disorders of the genito-urinary system;
• Lungs, tuberculosis or other disorders of the respiratory system;
• Physical impairment or deformity
• Stomach or oesophagus;
• Ulcers;

Do YOU currently have any symptoms of ill health or injury? (Note: it is not necessary to answer 'Yes' if only for colds or flu).
Yes    No

Are YOU taking any prescription medicines? (Note: it is not necessary to answer 'Yes' if only for colds or flu).
Yes    No

Do YOU participate in any hazardous pursuits or activities, including but not limited to motor sports in any form, rock climbing or mountaineering, water skiing, snow skiing, snow boarding, horse riding, canyoning, motor cycling, hang gliding, parachuting, abseilling, kite surfing, mountain biking, scuba diving, football (all codes), other body contact sports?
Yes    No

Are there any hazardous duties associated with your occupation (e.g. explosives/dangerous substances/working from heights)?
Yes    No

Have YOU ever had any policy or application for accident and illness insurance declined, modified, accepted at an increased premium, cancelled or refused renewal?
Yes     No

Have YOU ever claimed benefits from Workcover or Workers Compensation?
Yes    No

Have YOU ever claimed benefits under any accident or sickness insurance policy?
Yes     No    

Cover Required $
Please select 400 500 600 700 800 900 1000 1100 1200 1300 1400 1500 Other

Do you require a quote for illness cover?
Yes     No    

Declaration

By submitting this Declaration, the Applicant acknowledges:
- they are authorised by all the Applicants to make this Declaration,
- the contents of this form are true and complete,
- they are under a continuing obligation to immediately inform the insurer of any change in the particulars or statements contained in this form up until the contract is entered into,

General Advice Warning
As this advice has been prepared without considering your objectives, financial situation or needs, you should, before acting on this advice, consider its appropriateness to your circumstances. Our firm deals exclusively with QBE Insurance on Personal Accident Insurance. We have selected this insurer because of the quality of their product and their first class claims service. It is also important that you read and understand the Policy Wording that forms part of the policy wording.

Name of person making this declaration: