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Insurance Questionnaire

1Welcome

2Your Protection

3Your Health

New clients: Welcome to Lifegro Financial Planning. We look forward to the opportunity to work with you and assist you to achieve your financial and lifestyle goals. As part of our initial services we would like to ensure that your financial safety net is in place. This is to protect you and your loved ones and to enable you to continue to achieve your goals should you be injured or fall ill and be unable to work or generate an income, either temporarily or permanently. To help us understand more about your circumstances please complete the following questionnaire. Once submitted we will be in touch to to offer you solutions and options for your consideration. This is just the first step along your financial journey with us, but it is an important first goal to achieve.

Existing clients: As part of our ongoing service please re submit the questions in this questionnaire so that we may update your needs and either increase/reduce or otherwise adjust your current insurance cover in line with your goals, changing circumstances and available insurance options.

NOTE: This is an individual questionnaire and should be completed by each partner if you are a couple. (should take about 10 - 15 minutes to complete). We will use your answers along with all the other information we have gathered to provide you with options and solutions.

(Select "Next" to to begin)
Name
First Last
Email
Mobile
Do you consent to using electronic means to communicate with us and for us to act on instructions we receive from you electronically? You must answer "Yes" to proceed.*
Do you consent to using electronic means to communicate with us and for us to act on instructions we receive from you electronically? You must answer "Yes" to proceed.
- Yes
- No

Your answers to the following questions will help us to design a personal protection insurance solution that will protect you and your loved ones financially, if you die, become disabled or ill and unable to work, or suffer a major unexpected health event such as heart attack or cancer and many others.
What is your current occupation:
If yesterday you became disabled or ill and unable to work, how long would your leave pay and sick leave, or other ongoing income (eg customer payments, rent or dividends received), enable you to survive financially?
- Less than 1 month.
- Between 30 days and 60 days.
- Between 60 days and 90 days.
- Between 90 days and 6 months.
- Between 6 months and 2 years.
- Longer than 2 years.
- I am not sure - please discuss with me further.
If yesterday your partner died, in what capacity would you continue to work?
- Not applicable - I do not have a partner.
- I would continue to work full time until retirement. (and pay for child care if applicable).
- I would not work until our youngest child is 6, then I would work part time until he/she is 18, then full time until retirement.
- I would prefer not to have to work again.
- I am not sure - please discuss further with me.
If yesterday your partner became disabled, and needed full time care, in what capacity would you continue to work?
- Not applicable - I do not have a partner.
- I would continue to work full time until retirement. (and pay for the cost of a carer & housekeeper as applicable).
- I would not work until our youngest child is 6, then I would work part time until he/she is 18, then full time until retirement. (and we would pay for carer costs and housekeeping as applicable).
- I would prefer not to have to work again so that I could personally care for my partner.
- I am not sure - please discuss further with me.
Please provide an estimate of your overall expected future living costs below. Living costs are excluding mortgage/rent payments and excluding child education costs.
- I would only want to insure for the minimal living cost replacement (We estimate $40,000 pa for a couple, plus $5,000 p.a for each additional child).
- I would want my loved ones to be able to afford a modest living cost replacement (We estimate $50,000 pa for a couple, plus $7,000 p.a for each additional child).
- I would want my loved ones to be able to afford a comfortable living cost replacement (We estimate $60,000 pa for a couple, plus $9,000 p.a for each additional child).
- I have a detailed budget which can be used to estimate future living costs.
- I would like to provide estimated living costs per annum for each lifestyle stage.
Please estimate the following living costs per annum for each lifestyle stage:
1) 'Starting Out' (no kids), 2) 'Growing family' (with kids), 3) 'Empty Nesting' stage and finally into 4) 'Retirement':
Please provide an estimate of expected child education costs if applicable:
- Our children will be attending public schools and they will need to fund Uni/TAFE themselves through HECS
- Our children will attend Public Primary School, Private High school and will need to fund Uni/TAFE through HECS
- Our children will attend Public Primary School, Private High school and we would like to pay for Uni/TAFE for them
- Our children will attend Private School from Year 0 to year 12 and will fund Uni/TAFE themselves through HECS
- Our children will attend Private School from Year 0 to year 12 and we would like to pay for Uni/TAFE for them.
- I would like to provide estimated education costs per annum.
Please estimate the following educational costs per annum for each child:
1) Primary School, 2) High School, and 3) Uni/TAFE:
If yesterday you suffered a heart attack or severe cancer or other trauma diagnosis:
- I would like to have funds to pay off all my home loan debt, credit cards and car loans.
- I would like to have funds to pay off at least half of my home loan debt, plus credit cards and car loans.
- I am not sure - please provide options for us to consider.
- I would like to pay off a specific amount of debt.
Apart from your partner and children do you have any other dependents, or causes/charities that you would like to provide a donation to on your death and that would require additional life insurance to cover such a bequest
- No
- Yes
If "yes", please advise dependent or charity and amount of life cover:
If "yes", please advise dependent or charity and amount of life cover:

Your answers to the following health and lifestyle questions will help us to determine which insurer(s) would be most suitable for you. It will also allow us to identify any issues or concerns and try and resolve them before you apply for insurance and undergo underwriting assessment.
How would you rate your current health?
Please enter a number from 1 to 10.
On a scale of 10; '10' as Excellent to '1' as Poor.
Are you interested in wellness programs that may reduce your insurance premiums for following a healthy lifestyle (and lower resulting risk of incident)?
- yes
- no
- unsure
How tall are you?
What is your weight?
Have you smoked in the last 12 months?
- No
- Yes
If "yes", please provide details:
If "yes", please provide details:
Do you drink alcohol?
- No
- Yes
If "yes", on average how many standard drinks per week?
If "yes", on average how many standard drinks per week?
Have you ever suffered from or received treatment or medication for any of the following (check those boxes that apply)
- Mental health - stress anxiety, depression.
- High blood pressure
- High Cholesterol
- Cancer, tumor, leukemia, lymphoma or melanoma
- Epilepsy, seizure disorder, Multiple Sclerosis, Migraine, Neurological Disorder
- Diabetes
- Back or Neck pain, sciatica or any disorder of the spine or neck
- Arthritis, shoulder or knee pain or any disorder of the joints including knee reconstructions or arthroscopic surgery
- Asthma
- A blood condition including but not limited to HIV or AIDS
- Have you ever used illegal or illicit drugs
- Male: Any prostate disorder or abnormality
- Female : Have you had an abnormal pap smear or any gynecological condition
- I have medical/health concerns that I would prefer to discuss by phone or face to face (skip providing details below and we will call you to discuss further)
- None of the above
Please provide details such as condition, medication or treatment, resolved or still have ongoing symptoms, year of diagnosis, time off work as a result...
Have any of your parents, brothers or sisters suffered from any cardiac or cancer symptoms at an early age or any other serious critical illnesses or medical conditions?
- No
- Yes
If "yes" please provide details
If "yes" please provide details
Have you taken any drugs or prescriptions in the last 5 years (including illicit drugs , excluding any regular antibiotics)?
- no
- yes
If "yes" please provide details
If "yes" please provide details
Do you participate in any risky hobbies, pursuits or sports? (sky diving, scuba diving, dirt bike riding, motor racing etc etc......)?
- No
- Yes
If "yes" please provide details
If "yes" please provide details
I would prefer a flexible priced policy that can be reviewed and updated every few years to adjust for my circumstances.
- Agree
- Disagree
- Unsure
I would prefer to take a long term view of my insurance policy (generally more than ten years) and would like to consider options to pay higher premiums in early years so that I can save on lower premiums in future years. (Suits someone who tends to buy for the long term and who would not want to undergo underwriting/policy switching once they have a good policy in place)
- Agree
- Disagree
- Unsure
Where I have enough cash surplus I would prefer to pay for Income Protection personally outside super and claim a direct tax deduction for this expense
- Agree
- Disagree
- Unsure
Choose one of the following statements about the importance of cost, features and benefits
- I prefer to minimise the cost of insurance even if it means losing many features and benefits
- Generally I prefer to balance features and costs and weigh up the benefits
- Generally I prefer more features and benefits and am willing to pay for them
Do you have any other issues or concerns you would like us to consider when advising you on your Personal Protection Needs?
CAPTCHA

HOURS & LOCATION

Mon to Fri - 9 am to 5 pm

Lifegro Financial Planning
21/199 Balcatta Rd.
BALCATTA WA 6021

GET IN TOUCH

PHONE
(08) 6333 0800

EMAIL
[email protected]

NAVIGATE

Home
Let's Grow
Team
Experience
Contact Us

DOWNLOAD

Financial Services Guide
Part 1 - Privest Licensee Services Pty Ltd

.

Financial Services Guide

Part 2 - Nigel Owen

.

Financial Services Guide

Part 2 - Claudia Gould

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© 2020 LIFEGRO PTY LTD. / GENERAL ADVICE WARNING / TERMS AND CONDITIONS / POWERED BY THE AIR CREATIVE GROUP

Nigel Owen (ARN 236520), Claudia Gould (ARN 1273049) & Lifegro Pty Ltd ABN 25 113 414 814 / ARN 411643 are Authorised Representatives of Privest Licensee Services Pty Ltd AFSL 526603 | ABN 89 643 697 910

HOURS & LOCATION

Mon to Fri - 9 am to 5 pm

Lifegro Financial Planning
21/199 Balcatta Rd.
BALCATTA WA 6021

GET IN TOUCH

PHONE
(08) 9387 8010

EMAIL
[email protected]

DOWNLOAD

Financial Services Guide
Part 1 - Privest Licensee Services Pty Ltd

.

Financial Services Guide

Part 2 - Nigel Owen

.

Financial Services Guide

Part 2 - Claudia Gould

.

© 2020 LIFEGRO PTY LTD. / GENERAL ADVICE WARNING / TERMS AND CONDITIONS
POWERED BY THE AIR CREATIVE GROUP

Nigel Owen (ARN 236520), Claudia Gould (ARN 1273049) & Lifegro Pty Ltd ABN 25 113 414 814 / ARN 411643 are Authorised Representatives of Privest Licensee Services Pty Ltd
AFSL 526603 | ABN 89 643 697 910