Personal Risk Insurance Fact Find

Transcription

1 Personal Risk Insurance Fact Find Client Name: Date: Adviser Name: Has an FSG been provided to client? Yes No IMPORTANT NOTICE TO CLIENT The Corporations Act requires that an adviser making financial product recommendations must have reasonable grounds for making those recommendations. This means that an adviser must conduct an appropriate investigation as to the financial objectives, situation and particular needs of the client. The information requested in this form, is necessary to enable recommendations to be made and will be used solely for that purpose. We accept no liability for any advice given on the basis of inaccurate or incomplete information.

2 PERSONAL DETAILS Client Partner Your privacy is important to us, please refer to our privacy statement at the end of this document and in the Financial Services Guide (FSG) that you have been provided with. Surname Surname Given Name Given Name Preferred Name (if different) Preferred Name (If different) Date of Birth Gender Date of Birth Gender Age: Years Age: Years Planned Retirement Age? Planned Retirement Age? If we require clarification, please indicate who best to contact and the method you would prefer us to use: Name: Phone (W) (H) (M) Home Telephone Work Telephone Mobile Telephone Address (if regularly used) Residential Address Work Telephone Mobile Telephone Postal Address (if different from above)

3 YOUR DEPENDANTS Dependant (1) Dependant (2) Supporting the needs of your dependants into the future is part of risk management planning. Full Name Full Name Date of Birth Sex Age Date of Birth Sex Age Where funding is required for private schooling or university, a rate of $15,000 per years will be used unless you indicate otherwise. We will also factor in $2,000 per year for government schools. Relationship Relationship Dependant (3) Dependant (4) Full Name Full Name Date of Birth Sex Age Date of Birth Relationship Relationship Sex Age We factor childcare & domestic assistance to support children at age 25**. In earlier years the childcare will be most significant. As your dependants become young adults domestic issues such as home care, shopping, meal prep, washing, ironing etc. are the issues which make or break harmony age or not in at a all. single parent family. Now enter your children s age and circle the levels of schooling that you wish to cover. Child Current Age Schooling (circle) 1 Primary Secondary Tertiary 2 Primary Secondary Tertiary 3 Primary Secondary Tertiary 4 Primary Secondary Tertiary **Please advise if you would like domestic support calculated to a different age. Domestic support to what age?

4 PROFESSIONAL DETAILS Client Partner Your professional occupation and lifestyle choices are taken into account in the types of insurances and the premium rates for those insurances that are offered by life offices. Occupation Industry Full or Part Time? Other? Employer Occupation Industry Full or Part Time? Other? Employer Your income double or single finances your lifestyle & wealth creation opportunities. It is vital that this income is protected should a significant illness or accident befall you. Maximum available income protection is 75% of income (including superannuation contributions). Self Employed? Yes No Planned Retirement Age Long Service Leave owing? How much Sick Pay do you have owing? Would you continue to work in the event of the death or TPD of your partner? Y/N Full or Part time? Self Employed? Yes No Planned Retirement Age Long Service Leave owing? How much Sick Pay do you have owing? Would you continue to work in the event of the death or TPD of your partner? Y/N Full or Part time? Income Salary & Wages (including super) Salary & Wages (including super) Business Income Business Income Investment Income Investment Income Rental Income Rental Income Other Income Other Income Do you have a self managed superannuation fund (SMSF)? Yes/No Name of your S.M.S.F?

5 EXPENSES Knowing your expenses helps us determine the level of income that needs to be replaced. Rent/Mortgages Electricity/Natural gas Amount Frequency Annual (Circle) Amount Water and council rates Telephone/Internet/Mobile Groceries Medical Expenses General Insurance Clothing School Fees/Books/Uniforms Petrol/Car Other Total

6 Assets & Liabilities When determining the appropriate level of insurance that is required we base our advice on clearing debt and providing funding for the surviving family member s) in the event of the death, TPD or major trauma of a partner. Home Contents Car(s) Collectables Asset Value Liability Owner Liquidate? Land/Investment Property Other Property Mortgage Debt? Debt? Debt? Mortgage Mortgage Your lifestyle assets (eg. home, contents etc) are considered fixed. They would not be sold in the event of the death or TPD or major trauma of a partner (any debt on them would generally need to be cleared). Shares Business Asset Cash at hand Debt? Business Guarantee Business Liability Personal Loan(s) Overdraft You may choose to sell other assets in the event of the death or TPD or trauma of a partner. This can help reduce the amount of cover that is required. Please indicated your intentions. Please note that we will use an estimate of $100,000 to cover medical and lifestyle expenses for TPD and Trauma. Superannuation Assets** Client Spouse Total Joint Realisable & Other Assets Total Credit Cards ** Please remember to include any insurances you have as part of your superannuation fund in the Existing Insurances table on page 8 Total Joint Realisable & Other Liabilities Total Owner C: Client P: Partner J: Joint B: Business T: Trust S: Self Managed Super Fund

7 Life Style Decisions Calculating ongoing income. Financial security will provide peace of mind at a time of great personal stress. It is important to be clear about all areas of funding that need to be provided. That includes a realistic estimate of the proportion of your current shared income that the surviving partner will require. We usually recommend 66% of that shared income because our calculations will include clearing liabilities and where required funding school fees from the lump sum payment or from the sale of assets therefore some of your existing expenses will be extinguished. This may be offset by any income that will continue from other sources. Child care and/or domestic help, or medical care in the event of TPD, may also be needed. We factor in a rate of $20,000 pa and $25,000 pa respectively to address these two needs. These questions are based on the stereotypical family husband is the main income earner with the partner (wife) providing the main focus in raising the children. In this scenario the father usually intends to remain in full time work should death or TPD befall the mother. If your circumstances are different please alter as required. Where a partner is not currently working is there an intention to return to work at some time in the future. Yes / No Full Time/Part Time Potential earnings? $...pa If yes, when?. (eg. when baby is 2 years old) Where a partner is/will be working part time is there an intention to move to full time work at some time in the future. Yes / No Potential earnings? $...pa If yes, when?. (eg. When youngest starts school) Is 66% of your current shared income (to age 65) and appropriate level for a surviving partner? Yes / No If not, how much.% or $...pa We factor in a retirement income for a surviving partner of 50% of combined income. Is this an appropriate level for you? Yes / No If not, how much.% or $...pa Notes: special circumstances to be considered.

8 Health/Medical Details All applications for insurance are subject to a process known as underwriting before being accepted by the life company. The underwriters will consider your medical history and current state of health to decide if they will accept your application and on what terms (i.e. they try to determine what type of risk you are). Knowing some of your personal details can help us decide which underwriter is most appropriate for you. Please note that once we have submitted your application the life company will have their own set of questionnaires that you will be expected to complete. In some cases underwriting may also require you to undergo medical testing. Client Height: Weight: Current Health Status: Excellent Good Poor Do you smoke or have you smoked in the past 12 months? If so, what? How many? Have you ever had a previous insurance application declined or modified? If so what sort of cover and why? Do you have any current medical conditions? If so what? Have you ever consulted anyone for anxiety, stress or depression? If so, when and with who? Have you ever had a problem with blood pressure, cholesterol, cancer, diabetes or you your heart? If yes, please provide details: Partner Height: Weight: Current Health Status: Excellent Good Poor Do you smoke or have you smoked in the past 12 months? If so, what? How many? Have you ever had a previous insurance application declined or modified? If so what sort of cover and why? Do you have any current medical conditions? If so what? Have you ever consulted anyone for anxiety, stress or depression? If so, when and with who? Have you ever had a problem with blood pressure, cholesterol, cancer, diabetes or you your heart? If yes, please provide details: Have you ever had to consult a specialist for any medical condition? If yes, please provide details: Have you ever had to consult a specialist for any medical condition? If yes, please provide details: Do you participate in any hazardous activities? If so, what? Do you participate in any hazardous activities? If so, what?

9 EXISTING INSURANCES Policy 1 Policy 2 Name of Life Company Name of Life Company Policy Owner Policy Owner Policy Number Policy Number Life Insured Life Insured Type of Policy (Circle) Term Life TPD Trauma Income Protection Type of Policy (Circle) Term Life TPD Trauma Income Protection Commencement Date Commencement Date Sum Insured Sum Insured Lump Sump or monthly benefit Lump Sump or monthly benefit Waiting Period 14 /30 /90 /2yrs other Expenses insurance and Trauma only) Waiting Period 14 /30 /90 /2yrs other Expenses insurance and Trauma only) Benefit Period 2 / 5 / age 65 other Expenses insurance and only) Benefit Period 2 / 5 / age 65 other Expenses insurance and only) Annual / Monthly Level or Stepped To the Customer Service Department of the life office(s) mentioned above: I/We authorise the release of information relating to this policy / these policies to; Chris Payne & Margaret Jennings of Benefit Period Annual / Monthly Solutions 2 Wealth Management Pty Ltd Suite 7a, 346 Belmore Road Balwyn Vic 3103 A.B.N / AFSL / 5 / age 65 other Expenses insurance and only) Level or Stepped This authority will remain valid unless revoked to writing. Name: Name: Signed: Signed: Address:

10 EXISTING INSURANCES Policy 3 Policy 4 Name of Life Company Name of Life Company Policy Owner Policy Owner Policy Number Policy Number Life Insured Life Insured Type of Policy (Circle) Term Life TPD Trauma Income Protection Type of Policy (Circle) Term Life TPD Trauma Income Protection Commencement Date Commencement Date Sum Insured Sum Insured Lump Sump or monthly benefit Lump Sump or monthly benefit Waiting Period 14 /30 /90 /2yrs other Expenses insurance and Trauma only) Waiting Period 14 /30 /90 /2yrs other Expenses insurance and Trauma only) Benefit Period 2 / 5 / age 65 other Expenses insurance and only) Benefit Period 2 / 5 / age 65 other Expenses insurance and only) Annual / Monthly Annual / Monthly Level or Stepped To the Customer Service Department of the life office(s) mentioned above: Annual / Monthly Level or Stepped I/We authorise the release of information relating to this policy / these policies to; Chris Payne & Margaret Jennings of Solutions 2 Wealth Management Pty Ltd Suite 7a, 346 Belmore Road Balwyn Vic 3103 A.B.N / AFSL This authority will remain valid unless revoked to writing. Name: Name: Signed: Signed: Address:

11 Privacy Statement Solutions2 Wealth Management is dedicated to maintaining the privacy of your personal information. We collect and retain personal information for the purpose of providing financial services including the provision of financial advice and associated services, and the conducting of superannuation services administration. In doing so, we ensure we meet our obligations as an Australian Financial Services License Holder. Wherever practical we will request you to provide the information we require. However, we may use previously collected information or other information from reliable sources such as your superannuation fund, your accountant or the Australian Taxation Office at which time we will take reasonable steps to ensure it is accurate, complete and current. Solutions2 Wealth Management will only disclose your personal information to other parties where you have given your consent, it is implied, or we are required by law to do so. Examples of these parties include our auditors and other professional consultants, relevant government agencies, complaints handling organizations and your superannuation fund. If you do not provide us with your current personal information, we may not be able to provide you with the financial services that you require, or the services that we provide you may not be appropriate to your particular needs. You may request access personal information that we hold about you. Please contact us if you would like further information on our privacy policy.