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Insurance Pre-Assessment Form
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Name:
First Name
Last Name
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Email Id:
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Please enter valid email address
On average, how many standard alcoholic drinks would you drink per day:
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Have you ever been diagnosed with or had symptoms of any of the following:
Back Pain
Leg / Knee Injury / pain
Shoulder / Arm or hand injury / pain
Neck Injury
Diabetes
Cancer
Depression
Stress / Anxiety
Epilepsy
High Blood Pressure
High Cholesterol
Sleeping condition
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Have any of your immediate family members (parents, siblings or children only) been diagnosed with the following conditions:
High Blood Pressure
Heart Condition
Diabetes
Mental Health Condition
High Cholesterol
Cancer
Stroke
Any other hereditary discorders
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Do you have any pursuits and pastimes that you participate currently participate in or intend to participate in:
Motorbike Riding
Scuba Diving
Football (Soccer, Rugby, etc)
Mountain Bike Riding
Flying Planes
Rock Climbing
Cycling
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Have you ever made a claim for Disablement Benefits:
Workers Compensation
Centrelink (Excluding unemployment benefits
Income Protection
Trauma
Total and Permanent Disablement
Loan Protection
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If there anything else that you feel may be relevant:
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