Client Data Form

    Personal Details

    Life Insurance

    Total & Permanent Disability

    Trauma (Critical Illness)

    Income Protection

    General Details

    Client

    Full Name*
    Date of Birth*
    Gender*
    Mailing Address*
    Current Residency Status*
    Phone (Home)
    Phone (Mobile)*
    Email*

    Employment & Income Details

    Occupation*
    Gross Annual Income*$

    Client

    Do you have or foresee in the future that you will or may have outstanding financial commitments that will not be paid off by your estate in the event of your death or terminal illness?

    Financial or Financial-in-kind commitments may include but are not limited to:

    • mortgage and other debt servicing costs;
    • final expenses;
    • income replacement;
    • business commitments
    • business succession funding costs;
    • business continuity
    • medical costs;
    • transportation and accommodation costs;
    • personal and palliative care.

    To ensure you are able to pay your premiums in accordance with the selected premium structure for the period you intend to hold it.

    Are you/Do you have any of the following:

    • Earning income;
    • Personal savings;
    • Superannuation; or
    • Other financial capacity (e.g. family or other relationships)

    Client

    Options
    Life Insurance $

    Mode of Payment*

    Client

    Ownership – Trustee of the Trust

    Claim Payout – Governed by the SIS Act

    Client

    Do you have or foresee in the future that you will or may have outstanding financial commitments that will not be paid off should you be incapable of engaging in:

    • meaningful gainful employment; and/or
    • independent living due to total and permanent disablement.

    These financial or financial-in-kind commitments include but are not limited to:

    • mortgage and other debt servicing costs
    • income or revenue replacement
    • medical and rehabilitation costs
    • transportation and accommodation costs
    • personal care
    • palliative care
    • business commitments and/or business succession funding costs.

    To ensure you are able to pay your premiums in accordance with the selected premium structure for the period you intend to hold it.

    Are you/Do you have any of the following:

    • Earning income;
    • Personal savings;
    • Superannuation; or
    • Other financial capacity (e.g. family or other relationships)

    Client

    Options

    Total & Permanent Disability $

    Mode of Payment*

    Client

    Ownership – Trustee of the Trust

    Claim Payout – Governed by the SIS Act

    Client

    Do you have or foresee in the future that you will or may have outstanding financial commitments that will not be paid off should you suffer from a specified Trauma (Critical Illness) event.

    These financial or financial-in-kind commitments include but are not limited to:

    • mortgage and other debt servicing costs;
    • out-of-pocket medical expenses not covered by Medicare and/or health insurance;
    • transportation and accommodation costs;
    • personal and palliative care;
    • income replacement.
    • business commitments and/or business succession funding costs.

    To ensure you are able to pay your premiums in accordance with the selected premium structure for the period you intend to hold it.

    Are you/Do you have any of the following:

    • Earning income;
    • Personal savings;
    • Other financial capacity (e.g. family or other relationships)

    Client

    Options

    Trauma Cover $

    Mode of Payment *

    Client 1

    Client

    Are you currently earning an income?

    If Yes:

    Do you have a need to replace that income in the event that you are unable to earn an income due to an accident, sickness or illness ?

    To ensure you are able to pay your premiums in accordance with the selected premium structure for the period you intend to hold it.

    Are you/Do you have any of the following:

    • Earning income;
    • Personal savings;
    • Superannuation; or
    • Other financial capacity (e.g. family or other relationships)

    Client

    Income Protection (Monthly Amount)$
    Income Replacement Ratio (IRR)

    IRR70+ (70% throughout the benefit period and with a booster for the first 6 months of the benefit period)

    IRR70 (70% throughout the benefit period)

    IRR70/60 (70% for the first 2 years of the benefit period and 60% thereafter.)

    IRR60 (60% throughout the benefit period)

    IRR50 (50% throughout the benefit period)

    Waiting period
    Benefit Period

    Mode of Payment*

    Client

    Ownership – Trustee of the Trust

    Claim Payout – Governed by the SIS Act

    Ownership – Trustee of the Trust

    Claim Payout – Governed by the SIS Act

    General Details

    Client

    Height(Cm)*
    Weight(Kg)*
    Have you smoked any cigarettes in the last twelve months?*
    Additional Notes/Comments

    Client

    Client Declaration

    I/We hereby declare that:

    1. A Financial Services Guide (FSG) was provided to me/us and I/we have read and understood the document.
    2. I/we have received a General Advice letter advising of the General Advice Warning.
    3. I/we hereby affirm that the above information that I/we have supplied stating my/our income levels are true and correct to the best of my/our knowledge. I/we understand that if I/we do not supply the correct income details I/we may be disadvantaged at time of claim.
    4. I/we have answered all the TMD & General Health questions to the best of my knowledge as required by the product issuer to generate a quote.

    Client Authorisation

    Client Signature*