Data collection form Zurich FutureWise

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Bernice Benson
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1 Data collection form Zurich FutureWise This statement should be completed by the person to be insured. This form may be used to collect client information for later completion of the Zurich online application for FutureWise. Privacy reminder: The client information captured in this form is of a highly personal and sensitive nature. Accordingly, we remind you of your obligations to respect the privacy and sensitivity of that information, ensure the information is properly secured and use that information only for the purposes for which it has been collected. 1 Details of person to be insured Title: Full given name(s): Surname: Gender: Male Female Date of birth: Are you a smoker or have you smoked in the last 12 months? No Yes What is your employment status? Employed by third party (you are employed by an arm s length employer with no ownership interest in the business you work in) Self employed/business owner (sole trader, business owner, or you hold an ownership interest in the business you work in) Not employed What is your occupation? Please provide details of relevant qualifications: Residential address Street name and number: Suburb: State: Postcode: Postal address Street name and number: Suburb: State: Postcode: Work phone number: Home phone number: Mobile number*: *: * Mandatory. 2 Payment method How would you like to pay for your premiums? Monthly Annually Regular collection date SRAN BFS0049 V2 04/17 Credit card Credit card type: Visa MasterCard Credit card number: Expiry date: / Name on card: Zurich Australia Limited ABN , AFSLN Blue Street North Sydney NSW 2060.

2 2 of 12 Payment method (continued) Direct debit from bank account Branch number (BSB): Account number: Account name: For annual premiums only: Bpay Rollover from an external superannuation plan (for policies held within the Insurance-only Division of the Macquarie Superannuation Plan) Please note: If your employer is making contributions to the Insurance-only Division of the Macquarie Superannuation Plan on your behalf, only certain payment options will meet the new data and payment standard for superannuation contributions made from 1 July Your employer should contact the ATO for further information regarding the new data and payment standards. Registered to Bpay Pty Ltd ABN For applications to join the Insurance-only Division of the Macquarie Superannuation Plan What type of contributions are being made to fund insurance premiums? Personal Employer Super Guarantee Employer Salary Sacrifice Employer Other Spouse Please provide your Tax File Number: 4 Nominated beneficiaries (non-superannuation death benefit) The total of percentages must be 100% Name: LEGAL PERSONAL REPRESENTATIVE Relationship: ESTATE * Enter 0 or leave blank if you do not wish to nominate your estate. Percentage of benefit*: % Name: Date of birth: Sex: Male Female Relationship: Spouse Child Dependant Interdependent Brother Sister Mother Father Nephew Niece Legal guardian Other: Percentage of benefit: % Name: Date of birth: Sex: Male Female Relationship: Spouse Child Dependant Interdependent Brother Sister Mother Father Nephew Niece Legal guardian Other: Percentage of benefit: % Name: Date of birth: Sex: Male Female Relationship: Spouse Child Dependant Interdependent Brother Sister Mother Father Nephew Niece Legal guardian Other: Percentage of benefit: % Name: Date of birth: Sex: Male Female Relationship: Spouse Child Dependant Interdependent Brother Sister Mother Father Nephew Niece Legal guardian Other: Percentage of benefit: %

3 3 of 12 5 Occupation details A. What is your current employer s/business name? B. In which industry do you work? C. How many hours do you work per week? D. What percentage of your work involves manual work (including driving)? % E. Please describe your duties F. Do you work at heights above 10m, in a hazardous environment or with hazardous materials, offshore or underground? No u go to G Yes, please provide full details of your work environment including frequency working in this environment G. How long have you been in your current occupation/been self employed? Less than 12 months, please provide your last 5 years work history 12 months or more u go to H H. Are there any other occupations you are, or may become involved in; or are you anticipating a change in your current occupation, employment status or duties? No u go to I Yes, please provide details of the other occupation or change expected I. Do you work from home? No u go to J Yes, what percentage of your time is spent working from home? Less than 20% u go to J More than 20% Please provide details of your home work environment including the amount of time spent working from home and face-to-face contact with clients J. Have you ever been declared bankrupt, or has any entity you have been associated with been placed into receivership, liquidation or administration in the last 5 years? No u go to section 6 Yes, please provide details including date discharged and circumstances surrounding bankruptcy

4 4 of 12 6 Financial details A. B. What is your current annual income? $ Are you applying for Disability Income? Yes u go to C No u go to H C. To be completed if you are an employee u then go to G Last tax year Tax year before last Salary/Wage: $ $ Superannuation: $ $ Bonus: $ $ Other benefits (provide details below): $ $ TOTAL: $ $ Details of other benefits D. To be completed if you are self employed or if you own any part of the business you are working in Please select the term that best describes your business structure: Sole trader Company Partnership Trust Multiple entity business, how many entities does your business have? Please complete income details for each entity. If there are more than 4 entities please complete the Zurich Disability Income Calculator. Do you own 100% of the business? If only sharing ownership with spouse for income splitting purposes, select yes. Yes No, what is your share of the business? % How many owners/shareholders are there in your business? Please outline their % share and role in the business Do you have any employees? No Yes, how many? Full time: Part time: Casual: How many are income producing?

5 5 of 12 Financial details (continued) What is the business entity name? If more than 1 entity please complete income details for each entity. Annual income details as per your profit and loss account If you are providing full financial evidence u please go to E Last tax year a. What was your gross business income (turnover)? $ $ Tax year before last b. What were your business expenses? $ $ c. Total net business income before tax (a - b): $ $ d. What is your % share of net business income? % % e. Total share of net business income before tax (c x d): $ $ ADD BACK ITEMS Salary to self: $ $ Superannuation to self: $ $ Income split with spouse Salary/Wages and Super: $ $ Other Add back items (give details below): $ $ TOTAL INCOME (e + Add back items) $ $ Description of other addback items E. In the event of your disablement would your income continue for greater than 90 days (excluding other insurance and workers compensation)? No u go to F Yes, please provide details of continuing income and for what period income would continue F. What percentage of the business income do you personally generate? % G. Are you applying for Disability Income over $20,000 per month? No u go to H Yes, do you have net assets (excluding personal residence, family home and superannuation) exceeding $5 million and/or net investment or unearned income exceeding $250,000 per annum? No u go to H Yes, please provide details H. If you are applying for cover which requires us to obtain financial information from your accountant, do you give us permission to contact your accountant to clarify any particular issues? No u go to section 7 Accountants name: Practice name: Practice address: Yes, please provide your accountant s details Contact number:

6 6 of 12 7 Existing insurance cover A. Excluding this application, do you have or are you applying for Life Cover, Critical Illness, Total and Permanent No Yes Disablement or Income Protection? If Yes to above, please provide details: i. Cover type: Policy #: Sum insured: $ Start date: Company: ii. Disability Income: Monthly benefit: $ Waiting period: Benefit period: iii. Is policy being replaced? No Yes Benefit type: (eg Indemnity, Agreed Value or Endorsed Agreed Value) i. Cover type: Policy #: Sum insured: $ Start date: Company: ii. Disability Income: Monthly benefit: $ Waiting period: Benefit period: iii. Is policy being replaced? No Yes Benefit type: (eg Indemnity, Agreed Value or Endorsed Agreed Value) i. Cover type: Policy #: Sum insured: $ Start date: Company: ii. Disability Income: Monthly benefit: $ Waiting period: Benefit period: iii. Is policy being replaced? No Yes Benefit type: (eg Indemnity, Agreed Value or Endorsed Agreed Value) 8 Previous insurance and claims A. Have any proposals for Life, Critical Illness, Total Permanent Disablement or Income Protection on your life ever been declined, deferred or offered on non-standard terms? No u go to B Yes, provide the details below Reason cover was declined, deferred or offered on non-standard terms Non-standard terms on previous applications (if applicable) B. Have you ever received compensation payments for an accident, sickness or disability or is there a current claim being made? No u go to C Yes, date: Period paid: Provide the reason for the compensation payments: Has the claim been finalised? No Yes C. Do you have or will you be applying for any other Zurich Cover? No Yes

7 7 of 12 9 Personal Statement How do you want to complete the Personal Statement? A. By using TeleConnect what is the best date and time for Zurich LifeConnect to call you to book an appointment? Date: Time of day: Telephone number: B. By using WebConnect an link and password will be sent to the person to be insured. Once the person to be insured has completed the personal statement, it will be returned to the adviser, and the adviser will then need to submit the completed application to Zurich. Ensure a valid address and mobile number for the person to be insured have been provided. If you have selected A or B u go to section 17 and complete the medical authority. You will also need to complete the New business authorisation form attached to this form. OR C. The Adviser will be submitting the application u go to next question 10 Travel and residency A. Are you a citizen of Australia or New Zealand or are you a permanent resident of Australia? Yes No, please provide full details of current VISA subtype and residency plans including when you intend to apply for permanent residency. B. Have you any intention of living, working or travelling outside of Australia or New Zealand? No u go to section 11 Yes u go to next question C. What is your reason for travelling? Holiday Business E. Which country or countries are you travelling to? F. When do you intend to travel? G. How long will you be travelling? 11 Hazardous pursuits A. Do you, or are you likely to, take part in any hazardous activities? Examples of hazardous activities include: private aviation, motor sports, scuba diving, sailing, body contact sports such as martial arts or football and recreations involving heights or underground activities? No u go to next question Yes, what hazardous activities do you take part in, provide details of involvement, difficulty, frequency? B. Are you a member of the armed forces either full or part-time? No u go to next question Yes, please provide details of your main duties below

8 8 of Personal habits A. Do you currently smoke or have you smoked in the last 12 months? No u go to next question Yes, provide details of quantity smoked per day: B. On average how many standard glasses of alcohol do you consume per week? A standard drink is 1 single pub measure of spirits, a small (125ml) glass of wine or a 1/2 pint (250ml) of standard strength beer, lager or cider). C. Have you ever used or injected any drugs not prescribed by a medical attendant or received advice and/or counselling for excess alcohol consumption from any health professional? No u go to next question Yes, provide details of type, quantity, frequency, last use 13 Height/weight Height: cm/feet Weight: kg/lb Has your weight changed by more than 10kgs in the last 12 months? No u go to next question Yes. Was this change due to healthy lifestyle changes? Provide details below 14 Family history Have any of your natural parents or siblings suffered or died from any of the following conditions before the age of 60? Note you are only required to disclose family history information pertaining to first degree blood related family members living or deceased (mother, father, sister, brothers). Ischaemic heart disease and/or cerebrovascular disease (eg heart attack, angina, stroke, TIA, hypertension) Ovarian cancer Diabetes mellitus Hypertrophic cardiomyopathy Other cancer (eg bowel, prostate) Alzheimer s disease Parkinson s disease Huntington s disease Adult polycystic kidney disease Blood disorder Breast cancer Colo-rectal cancer (including polyposis of the colon) Multiple sclerosis Any other hereditary disorder If you selected any of the above, please complete the following schedule of family history Family member Condition Age diagnosed

9 9 of Personal medical history Do you have, or have you had, any of the following medical conditions? Check all for which the answer is Yes. 1. Any disease, disorder or condition relating to the heart and artery system for example chest pain, heart attack, heart enlargement, high blood pressure, raised cholesterol, blood clot or embolism, irregular heartbeat, heart murmur or heart valve disorders 2. Any disease, disorder or condition relating to the brain and nerves for example stroke, brain haemorrhage, head injury, epilepsy, fits, convulsions, migraines or persistent headaches. Numbness, tingling, dizziness, altered sensation, tremor, double vision, fainting, problems with memory, balance and/or any form of paralysis or multiple sclerosis 3. Any disease, disorder or condition relating to the digestive system for example stomach, oesophagus, bowel, pancreas, or liver disorder including hepatitis, ulcers, reflux, colitis, Crohn s disease, polyps, hernia or irritable bowel syndrome 4. Any disease, disorder or condition relating to the kidneys or urogenital tract for example kidney, bladder, urinary, prostate disorders including urinary tract infections, kidney stones or blood or protein in the urine 5. Any disease, disorder or condition relating to the respiratory system for example asthma, bronchitis, sleep apnoea, emphysema, chronic obstructive airways disease or any breathing disorder 6. Any disease, disorder or condition relating to the endocrine system (conditions related to hormones such as glandular, thyroid or insulin disorders) for example Diabetes Mellitus, raised blood sugar levels, sugar in the urine, glandular or thyroid disorders 7. Any disease or disorder of the blood for example anaemia, haemochromatosis, leukaemia or haemophilia 8. Any disease, disorder or condition relating to mental health or fatigue disorders for example anxiety, depression, stress, insomnia, nervous breakdown, dementia, panic attacks, schizophrenia, post-natal depression, chronic fatigue syndrome, eating disorders or suicide attempt? 9. Any disease, disorder or condition relating to the musculoskeletal system for example pain or problems relating to your back, neck, joints, bones or muscles including any form of arthritis, osteoporosis, slipped disc, sciatica, rheumatism, gout, myalgia or fibromyalgia or any other muscular problems, chronic pain disorders or repetitive strain injuries 10. Any disease, disorder or condition relating to the eye and/or ear other than minor defects corrected by spectacles or lenses for example keratoconus, iritis, glaucoma, optic neuritis, strabismus, blurred, double vision or hearing loss or tinnitus 11. Any disease, disorder or condition relating to cancer, benign tumours or cysts for example any tumour, lump, cyst or growth either malignant or benign. 12 Any disease, disorder or condition relating to the skin including skin lesions for example psoriasis, eczema, dermatitis or any skin lesion or skin cancer (eg squamous cell carcinoma, basal cell carcinoma, melanoma), mole or freckle that has bled, become painful changed colour or increased in size 13. Any disease, disorder or condition relating to communicable diseases Have you ever tested positive for HIV/AIDS, hepatitis B or C, or any sexually transmitted illness or are you awaiting the results of such a test (other than for this application)? FEMALES ONLY 14. Are you pregnant? Due date: Return to work date: 15. Have you ever had any complications with pregnancy or childbirth eg ectopic pregnancies, preeclampsia, or gestational diabetes? 16. Have you ever had an abnormal cervical smear test (pap), breast ultrasound or mammogram or have you had any symptoms of or sought advice or treatment for any condition of the cervix, ovary, uterus, breast or endometrium? PLEASE ANSWER THESE OTHER MEDICAL QUESTIONS RELATING TO CONDITIONS THAT HAVE NOT ALREADY BEEN DISCLOSED IN THIS APPLICATION 17. Have you, in the last five years, been absent from work or your place of study for a period of greater than five days through any illness or injury? 18. Have you ever had or are you considering having a genetic test where you received (or are currently awaiting) an individual result? 19. Have you, in the last five years, undergone or have you been advised to undergo any medical investigations or tests (eg colonoscopy, ultrasound, blood test or ECG)? 20. Have you, in the last five years, sought treatment from a physiotherapist, chiropractor or massage therapist that you have not already disclosed? 21. Do you contemplate seeking medical advice, investigation or treatment (including surgery) for any current health problems? 22. Are you currently experiencing any symptoms of illness, undergoing counselling, taking medication, or do you have any physical defect or infirmity?

10 10 of 12 Personal medical history (continued) If you selected any of the of the items on page 9, please complete the following details for each: Item: What is the name of the condition? When did it start? When did it cease (date of last symptoms)? Type of treatment? When did the treatment cease? Doctor s name: Address of practice/hospital: Degree of recovery? How long off work? Item: What is the name of the condition? When did it start? When did it cease (date of last symptoms)? Type of treatment? When did the treatment cease? Doctor s name: Address of practice/hospital: Degree of recovery? How long off work? Item: What is the name of the condition? When did it start? When did it cease (date of last symptoms)? Type of treatment? When did the treatment cease? Doctor s name: Address of practice/hospital: Degree of recovery? How long off work? Item: What is the name of the condition? When did it start? When did it cease (date of last symptoms)? Type of treatment? When did the treatment cease? Doctor s name: Address of practice/hospital: Degree of recovery? How long off work? Item: What is the name of the condition? When did it start? When did it cease (date of last symptoms)? Type of treatment? When did the treatment cease? Doctor s name: Address of practice/hospital: Degree of recovery? How long off work?

11 11 of Doctor s details Full name: Clinic/Surgery name: Clinic address: Phone number: How long have you been consulting with this doctor: 17 Medical authority Dear Doctor, I hereby authorise you or any other physician or surgeon or other person in your employ or associated with you to give Zurich Australia Limited or a service provider authorised to act or on behalf of Zurich any information which they may require and which you have acquired in a professional capacity. A photocopy of this authority should be accepted as my personal authority. Signature Date: Patient s name: Date of birth: Please return all relevant forms by mail to Zurich Customer Care, Locked Bag 994, North Sydney, NSW, 2059, by life.insurance@zurich.com.au or by fax

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Macquarie Life. Data collection

Macquarie Life. Data collection Macquarie Life Data collection You may use this form to collect client information for later completion of the Macquarie Life online application. At time of data collection, you may also obtain in writing