Check out our NEW HOME BUYERS COURSE! It has everything you need to know, and I’ll be by your side, guiding you every step of the way! Find out more by clicking on this text link

Check out our NEW HOME BUYERS COURSE! It has everything you need to know, and I’ll be by your side, guiding you every step of the way! Find out more by clicking on this text link

Make an appointment:

Apply for new insurance cover Insurance review 15-minute home loan chat via phone or zoom Buying a home

Please complete one of the pre-appointment forms first then we will be in touch to make an appointment. If you are unsure about which one to complete please call us on 03 214 9292.

Facebook
Instagram
TikTok
LinkedIn

Home
Services
Online course
- Disclaimer & terms of service
About us
Contact

Health questionnaire

My comments

Number of applicants

Individual
Couple

Applicant 1

First name

Last name

Mobile phone number

Date of birth

Gender

Male
Female
Other
Prefer not to disclose

Email address

Occupation and duties

e.g. 80% computer work, 10% driving, 10% admin

Who is your employer?

Do you have existing insurance?

Yes
No

Who is your insurance with?

Have you smoked, vaped or used an e-cigarette in the last 12 months?

Yes
No

Height

Weight

Have you ever been to hospital for an operation or treatment?

Yes
No

If yes, explain briefly

Are you on any regular medication, receiving advice or monitoring for a medical condition?

Yes
No

If yes, explain briefly

Have you ever suffered symptoms of or been diagnosed with problems in the following areas?

Cancer or tumour

Yes
No

If yes, explain briefly

Knees, hips or back

Yes
No

If yes, explain briefly

Arthritis

Yes
No

If yes, explain briefly

Heart or arteries / cholesterol

Yes
No

If yes, explain briefly

High blood pressure

Yes
No

If yes, explain briefly

Diabetes

Yes
No

If yes, explain briefly

Anxiety, depression or mental disorders

Yes
No

If yes, explain briefly

Asthma or lung disorder

Yes
No

If yes, explain briefly

Drug or alcohol dependency

Yes
No

If yes, explain briefly

Kidney/liver disease or disorders

Yes
No

If yes, explain briefly

Sleep problems

Yes
No

If yes, explain briefly

Blood disorders incl. HIV/AIDS

Yes
No

If yes, explain briefly

Chronic fatigue or pain

Yes
No

If yes, explain briefly

Other illness or condition not stated

Yes
No

If yes, explain briefly

Parents or siblings suffered from serious illness/condition

e.g. heart attack, cancer, etc.

Yes
No

If yes, explain briefly

In the last 5 years have you dealt with ACC over an injury? (e.g. physio, hospital treatment, off work)

Yes
No

ACC history

Please obtain a copy of your ACC history from this link.

Do you participate in any hazardous activities?

e.g. scuba diving, motor sport, parachuting, rock gliding, mountain climbing, caving, hang gliding, etc.

Yes
No

If yes, provide details

Applicant 2

First name

Last name

Mobile phone number

Date of birth

Gender

Male
Female
Other
Prefer not to disclose

Email address

Occupation and duties

e.g. 80% computer work, 10% driving, 10% admin

Who is your employer?

Do you have existing insurance?

Yes
No

Who is your insurance with?

Have you smoked, vaped or used an e-cigarette in the last 12 months?

Yes
No

Height

Weight

Have you ever been to hospital for an operation or treatment?

Yes
No

If yes, explain briefly

Are you on any regular medication, receiving advice or monitoring for a medical condition?

Yes
No

If yes, explain briefly

Have you ever suffered symptoms of or been diagnosed with problems in the following areas?

Cancer or tumour

Yes
No

If yes, explain briefly

Knees, hips or back

Yes
No

If yes, explain briefly

Arthritis

Yes
No

If yes, explain briefly

Heart or arteries / cholesterol

Yes
No

If yes, explain briefly

High blood pressure

Yes
No

If yes, explain briefly

Diabetes

Yes
No

If yes, explain briefly

Anxiety, depression or mental disorders

Yes
No

If yes, explain briefly

Asthma or lung disorder

Yes
No

If yes, explain briefly

Drug or alcohol dependency

Yes
No

If yes, explain briefly

Kidney/liver disease or disorders

Yes
No

If yes, explain briefly

Sleep problems

Yes
No

If yes, explain briefly

Blood disorders incl. HIV/AIDS

Yes
No

If yes, explain briefly

Chronic fatigue or pain

Yes
No

If yes, explain briefly

Other illness or condition not stated

Yes
No

If yes, explain briefly

Parents or siblings suffered from serious illness/condition

e.g. heart attack, cancer, etc.

Yes
No

If yes, explain briefly

In the last 5 years have you dealt with ACC over an injury? (e.g. physio, hospital treatment, off work)

Yes
No

ACC history

Please obtain a copy of your ACC history from this link.

Do you participate in any hazardous activities?

e.g. scuba diving, motor sport, parachuting, rock gliding, mountain climbing, caving, hang gliding, etc.

Yes
No

If yes, provide details

Services

© 2024 Brenda Nom • Disclosure statement • Complaints process

Home
Services
Online course
- Disclaimer & terms of service
About us
Contact
Facebook
Instagram
TikTok
LinkedIn