Health questionnaire • Brenda Nom Mortgage & Insurance Adviser

My comments

Number of applicants

Individual
Couple

Applicant 1

First name

Last name

Mobile phone number

Address

Date of birth

Gender

Male
Female
Other
Prefer not to disclose

Email address

Relationship status

Are you currently in the process of securing lending through us, or have you completed lending with us within the last 12 months?

Occupation and duties

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

Who is your employer?

Do you have existing insurance?

Who is your insurance with?

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

Height

Weight

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

If yes, explain briefly

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

If yes, explain briefly

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

Cancer or tumour

If yes, explain briefly

Knees, hips or back

If yes, explain briefly

Arthritis

If yes, explain briefly

Heart or arteries / cholesterol

If yes, explain briefly

High blood pressure

If yes, explain briefly

Diabetes

If yes, explain briefly

Anxiety, depression or mental disorders

If yes, explain briefly

Asthma or lung disorder

If yes, explain briefly

Drug or alcohol dependency

If yes, explain briefly

Kidney/liver disease or disorders

If yes, explain briefly

Sleep problems

If yes, explain briefly

Blood disorders incl. HIV/AIDS

If yes, explain briefly

Chronic fatigue or pain

If yes, explain briefly

Other illness or condition not stated

If yes, explain briefly

Parents or siblings suffered from serious illness/condition

e.g. heart attack, cancer, etc.

If yes, explain briefly

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

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.

If yes, provide details

Applicant 2

First name

Last name

Mobile phone number

Address

Date of birth

Gender

Male
Female
Other
Prefer not to disclose

Email address

Relationship status

Are you currently in the process of securing lending through us, or have you completed lending with us within the last 12 months?

Occupation and duties

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

Who is your employer?

Do you have existing insurance?

Who is your insurance with?

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

Height

Weight

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

If yes, explain briefly

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

If yes, explain briefly

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

Cancer or tumour

If yes, explain briefly

Knees, hips or back

If yes, explain briefly

Arthritis

If yes, explain briefly

Heart or arteries / cholesterol

If yes, explain briefly

High blood pressure

If yes, explain briefly

Diabetes

If yes, explain briefly

Anxiety, depression or mental disorders

If yes, explain briefly

Asthma or lung disorder

If yes, explain briefly

Drug or alcohol dependency

If yes, explain briefly

Kidney/liver disease or disorders

If yes, explain briefly

Sleep problems

If yes, explain briefly

Blood disorders incl. HIV/AIDS

If yes, explain briefly

Chronic fatigue or pain

If yes, explain briefly

Other illness or condition not stated

If yes, explain briefly

Parents or siblings suffered from serious illness/condition

e.g. heart attack, cancer, etc.

If yes, explain briefly

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

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.

If yes, provide details

Authorisation confirmation

By ticking this box, I confirm that I have the authority to permit the information provided on this form to be sent to one of our insurance companies for the purpose of determining any potential loadings or exclusions. This includes obtaining permission on behalf of my partner, if applicable.