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Disability Fact Finder

Injury & Illness policies are taken out to cover your average weekly wage in the event of an injury or illness (depending on the policy taken). This policy is cancellable, which means the insurer may decline to renew the policy. The benefits payable are for up-to two years with various excess options.

If you require a Non-Cancellable policy please contact us.

In order for City Rural Insurance Brokers to provide you with an Obligation Free Quote, please complete the following.

Fields designated in RED require completion
GENERAL INFORMATION
Contact Name
Street address
 Suburb/Town
State
 Postcode
Email Address
 Phone
Fax
 Mobile Phone
Preferred method of contact
Email   Phone   Fax 		Occupation
Current Insurer 
Expiry date 
Has any insurer in respect of any insurance policy held by you ever:
(a) Refused to renew / cancelled or terminated a policyYes   No
If YES please give details below:

(b) Refused a claim or required an increased premium under the policy?Yes   No
If YES please give details below:

(c) Imposed special conditions under the policy?Yes   No
If YES please give details below:

(d) Have you been convicted on any criminal offence or been declared bankrupt? Yes   No
If YES please give details below:

(e) Have you had any claims in the past 5 Years inc Workers Compensation?Yes   No
If YES please give details below:

PERSONAL INJURY OR PERSONAL INJURY & ILLNESS
Benefit payable for limited period. Policy can be cancelled by Insurance Company
Definition of Income - Personal Exertion Earnings, before Tax but after deductions of Business Expenses

Current Income $
Should you require Non Cancellable Policy we will refer you to an appropriate consultant.
Insured's Name
DOB
 Height
 Weight
 Male Female
Death
$		 Weekly Injury
$		 Weekly Illness
$		 Smoker?   Yes No
Period of Benefit
52 Weeks   104 Weeks 		Waiting Period
14 Days   30 Days
Are You Self Employed
Yes   No 		If yes, for how long?
INSURED PERSON'S MEDICAL HISTORY
Give details to "yes" answers under each question. Include name and address of doctors, health practitioners or hospital attended.
[a] Have you consulted any doctor, physiotherapist, chiropractor or any other health practitioner or been confined in hospital during the past five years? Yes   No
If yes, please supply details.
[b] Have you every been declined injury, sickness or life insurance, or been issued such insurance which has been postponed, modified, rated up, cancelled or renewal refused? Yes   No
If yes, please supply details.
[c] Have you ever claimed for benefits under any injury or sickness insurance or Worker's Compensation? Yes   No
If yes, please supply details.
[d] Will the total amount of your weekly compensation during disablement from this and all other sources exceed your weekly salary or income? Yes   No
If yes, please supply details.
[e]Do you engage in any hazardous pastimes or pursits? e.g. football, motor sport Yes   No
If yes, please supply details.
[f] Have you ever had abnormal blood pressure, ulcers, diabetes, tuberculosis, cancer, paralysis, arthritis or rheumatism, any disorders of the mental, respiratory, genito-urinary, digestive, or circulatory systems, or of the back, spine, eyes or heart, or suffered anxiety state, nervous exhaustion or breakdown, psychosis or any form of mental disorder, or any physical impairment or deformity? Yes   No
If yes, please supply details.
[g] Are there any reasons that would cause you to consider yourself not presently in good health? If yes, give details. Yes   No
If yes, please supply details.
[h] Are you currently planning or considering having treatment or advice from any doctor, health practitioner or hospital? Yes   No
If yes, please supply details.
I have read the Duty of Disclosure (view)
Duty of Disclosure

In order to make an informed assessment of the risk and calculate the appropriate premium, your insurer needs information about the risk you are asking it to insure.

For this reason, before you enter into a contract of insurance, you have a duty under the Insurance Contracts Act 1984 to disclose to your insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer’s decision whether to accept the risk and, if so, on what terms. The duty also applies when you renew, extend, vary or reinstate a contract of insurance.

You do not have to disclose anything that:

  • Reduces the risk to be undertaken by the insurer;
  • Is common knowledge;
  • Your insurer knows, or in the ordinary course of its business, ought to know; or
  • If the insurer has waived your obligation to disclose.
If you do not comply with your duty of disclosure, your insurer may be entitled to reduce its liability in respect of a claim or may cancel your contract of insurance. If the non-disclosure was fraudulent, the insurer may be able to avoid (or cancel) the contract of insurance from its beginning. This would have the effect that you were never insured.

One important matter to be disclosed is the history of losses suffered by the person seeking insurance or any closely associated person or entity. As you are responsible for checking that you have made complete disclosure, we suggest that you keep an up to date record of all such losses and claims.
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Australian Financial Services Licence No 237491 – General Insurance Broker

 

 

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Australian Financial Services Licence No 237491

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