Personal Insurance Preassessment
Personal & Contact
Health Overview
Tick any categories that apply, then enter disclosures under the relevant headings. Examples are shown inline.
Medications
Please provide details of any medications that you are currently taking, or have been taking in recent history, that you haven't already disclosed above.
Hazardous pastimes
Provide details of any activities that you participate in that an insurer may consider risky. This includes things like team sports (even social), organised fitness events, water based activities, any form of aviation (other than as a fee paying passenger), motorsports etc.
Family history
Provide details of any serious illnesses that your immediate family members (mother, father, brothers or sisters) have experienced/been diagnosed with. Disclose things like cancer, heart conditions, neurological conditions (such as MS, Alzheimer's or Muscular Dystrophy).
Working arrangements
Employment status, hours/week, leave balances, % manual duties with examples, travel details.
Acknowledgement
I confirm that I have completed this form comprehensively and to the best of my knowledge. I understand that if I do not disclose something notable, and this leads to an application being declined or additional work, fees may be payable as outlined in the Custodian Insurance Terms of Engagement.