Weight
kgs stones and lbs
(b) Have you smoked in the last 12 months?
(c) Do you use, or have you ever used recreational and/or non-prescription drugs (except 'over the counter' medications)?
(d) How many standard alcoholic drinks do you have per week on average?
Alcohol:
Please select 0 to 4 units daily 4 to 5 units daily 6 to 8 units daily 9 to 12 units daily More than units daily
(e) Have you ever received or are you considering seeking medical advice, counselling, or treatment for the use of alcohol, drugs or gambling?
If 'Yes', give details:
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(f) Are you a permanent resident of New Zealand?
(g) Do you intend to live, work or travel overseas, except for Australia or the Cook Islands in the next 12 months?
If 'Yes', give details:
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(h) Have you ever engaged, or are you likely to engage in any hazardous or high-risk occupation, activity, sport or pastime? (e.g. aviation, motor sports, diving, mountaineering)
If 'Yes', give details:
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(i) Have either of your parents or any of your brothers or sisters suffered from (before the age of 60): diabetes, stroke, heart disease, high blood pressure, kidney disease, polycystic kidney, cancer (please specify type), Huntington's chorea, multiple sclerosis, mental illness, dementia, or any other hereditary or familial disease.
If 'Yes', give details:
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(j.) Have you ever suffered from any of the following illnesses/conditions?
1.
Stroke, epilepsy, or neurological disorder (e.g. motor neuron disease, MS, paralysis, seizures)
Yes No
2.
Mental illness, nervous disorder, stress, depression, fatigue or phobia
Yes No
3.
Any disease or disorder of the eyes, ears, nose or throat (including loss of sight, hearing or speech)
Yes No
4.
Thyroid disorder or any other glandular condition
Yes No
5.
Respiratory disorder (e.g. asthma, bronchitis, sleep apnoea, breathing problems)
Yes No
6.
Chest pain, heart complaint, high blood pressure or high cholesterol
Yes No
7.
Any condition of the gastrointestinal tract or bowel (e.g. irritable bowel, Crohn's disease, ulcers, colitis, reflux)
Yes No
8.
Obesity (e.g. stomach stapling)
Yes No
9.
Liver disease or disorder (e.g. hepatitis)
Yes No
10.
Diabetes or abnormal blood sugar level
Yes No
11.
Kidney, bladder, genital or urinary problem (e.g. prostate, urinary incontinence, kidney stones)
Yes No
12.
An injury, disease or disorder of muscle, joint or bone (including arthritis, rheumatism, SLE, gout)
Yes No
13.
Cancer, tumour, cyst, breast lump, abnormal moles, skin disorder or any other lesion
Yes No
14.
Blood disorders (e.g. anaemia, varicose veins, blood clots, bleeding tendencies)
Yes No
15.
AIDS or HIV antibodies
Yes No
16.
Any other illness or condition not listed above
Yes No
17.
FEMALES ONLY: Any condition relating to the breast, cervix, uterus, fallopian tube, ovary or the female genital tract (e.g. abnormal smear, endometriosis, heavy/painful/irregular menstrual bleeding, fibroids)
Yes No
(k.) Other than what you have disclosed above:
Have you experienced any health problems within the last five years, or;
Have you ever had, been referred for, or are you considering seeking any medical advice, counselling, investigations, blood tests, treatment or operations?
Condition
Date of first symptoms
Date of last symptoms
Details (include treatment, test results, time off work, recurrence, current status) Details
Are you receiving or have you been advised that treatment followup is required? Followup treatment required?
Have you ever had any reoccurance of this condition? Any reoccurance?
(complete if applying for Total Permanent Disablement or Waiver of Premium)
(a) What is your current main occupation?
(b) Are you:
(d) Are you intending to change your occupation or duties ?
Yes No
(e) Number of hours worked
hours per week
(f) Do you work from home?
Yes No
(g) If 'Yes', give details of your home set up and % of time spent in this workplace:
(h) Do you have any other occupation?
Yes No
(i) Give details of your current and previous occupations during the last five years
Date from
Date to
Occupation
Employer
(j) Have you ever been declared bankrupt and/or convicted of any criminal offence?
Yes No
IMPORTANT NOTICE: Your duty of disclosure
Before you enter into this contract of Insurance ('Insurance'), you have a duty to disclose to Sovereign Assurance Company Limited ('Sovereign') every matter that is material to its decision concerning whether to accept the risk of the Insurance and, if so, on what terms.
You have the same duty to disclose those matters to Sovereign before you apply to vary or reinstate the Insurance. If you fail to comply with your duty of disclosure to us,
and we would not have issued the Insurance on the same terms if disclosure had been made, we may cancel or avoid the Insurance from inception.
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Validation:
Please help us distinguish between a real individual and spam robots by typing the 3rd word in the list below:
"hope beautiful kind flower wonderful"
Submit Application - the above application will be sent electronically and mailed to you for checking and signature.
Printable Application - an application suitable for printing will be produced for your signature and mailing (or if submitted to retain as a personal record)