(Form B)
Complete this form if you are applying for Life only, Life and TPD or Income Protection cover for:
• more than $6,000 per month for Income Protection cover;
• more than $800,000 for Life only or Life and TPD cover;
• or if you answer ‘Yes’ to any questions in Section D of Short Form A1 or A2.
A – Insured details
Postal address
Main occupation
/ / Date of birth
Given name(s) Surname
Investor account number Are you a member of a Superannuation Service with insurance
cover administered by Avanteos Investments Limited?
No Yes
Sex Male Female
State Postcode Country
Title
Mr Mrs Ms Miss Other
Are you a permanent resident of Australia?
Yes
No Please provide details below
Do you work (on average) less than 15 hours per week or more than 60 hours per week? No Yes
Annual salary (including average bonus for last 3 years) $
B – Insurance cover
Please read the ‘duty of disclosure’ in Section N before completing this Personal Statement.
Type of insurance being applied for:
Life only Amount of cover
$ OR
Life and TPD
Amount of TPD cover $
Amount of Life cover $
Occupation type (only applicable for TPD cover for professional employees) Please provide details below
Do you wish to apply indexation (CPI) to your selected level of Life only, or Life and TPD cover?
No Yes
D – Insurance history details
2 Has an application for life, disability, trauma, accident or sickness insurance on your life ever been declined, deferred or accepted with a loading, exclusion or special terms?
1 Other than this application, do you have or have you recently applied for life, total and permanent disability, trauma or income protection insurance on your life with CommInsure or any other insurance company?
No No
Yes Please provide details below Yes Please provide details below
Fund or insurance company name Date commenced Terms offered and reason / /
/ /
Fund or insurance company name Type of cover Insurance benefit To be
replaced? Policy Number Date commenced
$ / /
$ / /
3 Are you claiming or have you ever claimed a benefit from any source, e.g. TPD benefit from any superannuation fund, workers compensation, disability pension, Veterans’ Affairs pension or any other insurance policy providing accident or sickness benefits?
No Yes Please provide details below
Benefit type/source/reason for claim Claim date Claim amount Date claim finalised
/ / $ / /
/ / $ / /
C – Occupation risk rating
1 Are the duties of your occupation limited to Professional, Managerial, Administrative, Clerical, Secretarial or similar ‘white collar’ tasks which do not involve manual work and are undertaken entirely (or at least
80%) within an office environment (excluding travel time from one office environment to another)? No Yes 2 Are you earning in excess of $80,000 per annum from your profession? No Yes 3 Are the duties of your occupation limited to the supervision of manual workers (with no hands on
involvement in manual work), site inspections or a sales representative with at least 80% of your time
spent out of the office? No Yes
4 Are you in a skilled occupation with a light amount of manual work (less than 20%)? No Yes 5 Does your occupation involve any of the following: driving in excess of 800 kilometres from base, flying
other than as a fare paying passenger, working at heights over 15 metres, working offshore or in the mining or oil and gas industries, working on production lines or performing unskilled factory work,
scuba diving or handling explosives or weapons? No Yes
E – Activities and pastimes
Tick (✔) yes or no 1 Do you currently engage in, or intend to engage in, any of the following sports or hazardous activities:
• Flying (other than as a fare paying passenger on a commercial airline)? No Yes • Underwater diving? (Maximum Depth m) No Yes • Motor sports of any kind, e.g. rally driving, trail bike riding, ocean racing? No Yes • Football of any code (including touch football or Oz tag)? No Yes • Any other sport or hazardous activities, e.g. parachuting, hang-gliding, body contact sports,
paragliding, competitive water sports or recreations involving heights? No Yes If you answered ‘Yes’ to any of the above, please provide further details below
Tick (✔) yes or no
Do you receive income from participating in this activity/ies? No Yes
Tick (✔) the appropriate box At what level do you participate?
Recreational only (non-competition) Recreational with competition Semi-professional/professional Number of times you participate on average in this activity/ies per annum (e.g. hours flown, number of drives, events etc.)
F – Personal health details
or or
Yes No
Substance smoked Per day Per week Per year
Yes No
Please provide the average number of drinks consumed
Per day Per week Per year
1 What is your height and current weight?
Height
cm
Weight
ft/ins kg st/lbs
2 Have you smoked tobacco, or any other substance, at any time during the last twelve months?
Please indicate type (e.g. cigarettes, cigars, etc.) and average amount smoked below
3 Do you drink alcohol?
G – Family history
1 Have any of your immediate family (parents, brothers, sisters) suffered from, or been diagnosed with, any of the following:
a Heart problems, stroke, high blood pressure, diabetes?
Yes No
Unknown
b Cancer (breast, ovarian, cervical, bowel or other)?
(please specify type)
c Any other inherited or hereditary disease (e.g. huntington’s disease, polycystic kidney, muscular dystrophy, familial polyposis, etc.)?
(please specify type)
Approximate age Age at death Please complete the table in (c) below
E - Activities and pastimes continued
I – Lifestyle declaration
To the best of your knowledge, is there any possibility that you have ever been infected with, or have you ever tested positive for, AIDS (Acquired Immune Deficiency Syndrome), HIV (Human Immunodeficiency Virus) or hepatitis, or are you in a high-risk category (eg injected drugs other than as prescribed by a medical practitioner, shared needles, engaged in unprotected male to male sexual intercourse, worked as or, engaged the services of a prostitute)?
Yes No
Please provide details below
Please note: If you answered ‘Yes’ to the declaration above, you will be asked to complete a specific lifestyle questionnaire.
H - Doctor details
1 What is the name and address of the last doctor or medical centre you visited?
State Postcode
Full name of doctor
Address
Phone number ( )
Facsimile number ( )
2 a When did you last see a doctor?
b Reason for last consultation?
c What was the result/outcome from your last consultation? (please tick () the appropriate box) Referral to specialist/health professional
Tests conducted – results pending Not fully recovered yet
Ongoing treatment (e.g. ventolin inhaler)
Routine tests conducted – results all clear/normal
All clear/normal/full recovery – no tests or prescribed treatment required (other than contraceptive and cold/flu medication) 3 Is the doctor/medical centre mentioned above your usual doctor/medical centre?
4 How long have you been a patient of this doctor or medical centre?
Yes No
6 to 12 months ago 12 months to 2 years ago Over 2 years ago Within the last month 1 to 3 months ago 3 to 6 months ago
Years Months
If less than 12 months, please provide details of your previous doctor/medical centres.
Full name of doctor
Address
Phone number ( )
Facsimile number ( )
State Postcode
J – Medical history
Have you ever had, or sought advice or treatment, experienced symptoms, or suffered from any of the following: Tick (✔) yes or no
1 Asthma, bronchitis or any other lung complaint? No Yes
2 Cysts, moles, sunspots or skin lesions? No Yes
3 Back, neck, shoulder, knee, elbow complaints, sciatica, disc or spine complaints, or injury of the joints,
bones or muscles? No Yes
4 Depression or mental disorder
(including but not limited to stress, anxiety, panic attacks, behavioural or nervous disorder)? No Yes
5 Diabetes or abnormal blood sugar No Yes
6 Chest pains, heart complaint, heart murmur, high blood pressure, raised cholesterol,
palpitations or rheumatic fever? No Yes
7 Stroke, paralysis, neurological disorder, multiple sclerosis or blood vessel disorder? No Yes
8 Cancer, tumour or melanoma? No Yes
9 Thyroid, glandular or pancreatic disorder? No Yes
10 Gastric or duodenal ulcer, persistent indigestion, irritable bowel or other bowel disorder? No Yes 11 Any disorder of the gall bladder or liver (including hepatitis B, C or raised liver function)? No Yes
12 Varicose veins, haemorrhoids or hernia? No Yes
13 Disorder of the kidney, bladder or prostate, blood in urine or kidney stones? No Yes 14 Epilepsy, fits of any kind, fainting episodes, or recurring headaches or migraines? No Yes 15 Chronic fatigue syndrome, lethargy, sleep apnoea or any sleeping disorder? No Yes 16 Arthritis, gout, osteoporosis, fibromyalgia, Repetitive Strain Injury (RSI) or any chronic pain syndrome? No Yes
17 Eczema, dermatitis, psoriasis, or any other skin disorder? No Yes
18 Anaemia, leukaemia, haemophilia, haemochromotosis or any other blood disorder? No Yes 19 Any impairment of sight (other than corrected by glasses or lenses) or blurred vision? No Yes
20 Any impairment of hearing, including tinnitus, or speech? No Yes
21 Any sexually transmitted diseases? No Yes
22 Any other illness, injury, disease or disorder not mentioned above? No Yes 23 Other than those conditions mentioned above, are you taking any regular prescribed medication
(excluding contraceptives)? No Yes
24 Within the last three years, have you had:
• Any blood tests which revealed an abnormality?
• Any tests such as ECG, X-ray (excluding broken bones or joint strains), genetic test or ultrasound
(other than for pregnancy)? No Yes
25 Are you considering seeking medical advice, treatment, tests or surgery in the future? No Yes
26 Have you ever had a genetic test? No Yes
Females Only
27 Are you currently pregnant? No Yes
• If yes: due date for birth of baby? / /
28 Have you ever had any complications with pregnancy or childbirth (e.g. diabetes, ectopic pregnancy)? No Yes
K - Specific medical questionnaires
If you have answered ‘Yes’ to any of questions 1 to 4 in Section J, please complete the relevant specific questionnaire below.