Associatedmarine.co.nz

Underwriting
Asthma questionnaire
This form is to be completed only on request by Zurich Underwriting. To be completed by the life insured. Please avoid delays by checking that all questions have been answered ful y and where appropriate use BLOCK LETTERS.
Policy number(s)
Your duty of disclosure
Before you enter into a contract of life insurance with an insurer, you have a duty, under the Insurance Contracts Act 1984, to disclose to the
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
of the insurance and, if so, on what terms.
You have the same duty to disclose those matters to the insurer before you extend, vary or reinstate a contract of life insurance.
Your duty of disclosure however does not require disclosure of a matter: • that diminishes the risk to be undertaken by the insurer • that your insurer knows or, in the ordinary course of business ought to know • if compliance with your duty in relation to that matter is waived by the insurer.
Your duty of disclosure continues until the insurer has informed you as to whether the insurer accepts or declines your application. This means that you must advise the insurer of any changes to the information included in your application up until the date that the insurer confirms in writing that the application has been accepted or declined.
In particular, you should advise Zurich of any changes in medical or physical conditions, and of any visits to medical service providers.
Non-disclosure
If you fail to comply with your duty of disclosure and the insurer would not have entered into the contract on any terms if the failure had not occurred, the insurer may avoid the contract within 3 years of entering into it. If your non-disclosure is fraudulent, the insurer may avoid the contract at any time.
An insurer who is entitled to avoid a contract of life insurance may, within 3 years of entering into it, elect not to avoid it but to reduce the sum that you have been insured for in accordance with a formula that takes into account the premium that would have been payable if you had disclosed all relevant matters to the insurer.
Your Privacy
Zurich is bound by the National Privacy Principles. In completing the forms or questions herein you will be providing us with your personal
and, perhaps, sensitive information. The col ection and management of this information is governed by the Privacy Act 1988. For a more
detailed explanation of Zurich’s Privacy Policy please visit our website at www.zurich.com.au or contact the Zurich Privacy Officer on 132 687
or email us at [email protected].
1 Life insured details
Zurich Australia Limited ABN 92 000 010 195, AFSLN 232510. 5 Blue Street North Sydney NSW 2060.
Zurich Australian Superannuation Pty Limited ABN 78 000 880 553, AFSLN 232500. 5 Blue Street North Sydney NSW 2060.
2 Asthma details
(a) When did you have your first asthma attack? / / (b) How many attacks do you have per year? (c) What term best describes your asthma? (d) Are your symptoms precipitated by seasonal changes, exercise, respiratory infections, etc.? (e) Do you suffer from the fol owing between attacks? (i) wheezing (f) How much time have you lost from work over the past 2 years because of asthma? (g) Please provide details of doctors who have treated you for asthma (if additional space is required, please attach a separate sheet) If ‘Yes’, please provide details of medication and dosage (i) `Have you ever had your chest x-rayed or undergone any pulmonary function tests? If ‘Yes’, please provide dates, tests and results (j) Have you ever been treated with steroids, cortisone or prednisone? (k) Have you ever been hospitalised because of asthma? Date admitted
Date discharged
Name of hospital
3 Declaration
The proposed life insured states as fol ows: 1. I have read and understood all of the statements, questions and answers in the questionnaire. In particular, I acknowledge my duty of disclosure to Zurich as described at the beginning of this form.
2. Each statement that I have made to Zurich or any other person in relation to my application for insurance and in this questionnaire is true 3. I acknowledge that Zurich will rely on statements in this questionnaire in deciding whether to issue an insurance policy and what terms 4. I authorise Zurich to disclose any information in relation to my application for insurance to any person for the purpose of assisting Zurich to make a decision in relation to my application for insurance.
5. I understand that the insurance applied for shall not become effective until Zurich accepts my application.
6. I authorise my medical practitioner or other professional (ie accountant) to disclose any information that they may possess about me to Zurich in relation to my application for insurance or any claim under it.
7. I authorise Zurich to approach any person named in this questionnaire to verify any aspect. In the same way, I authorise any person named in my questionnaire to disclose any information they may possess about me to Zurich.
Any questions? Call 131 551
Please return the completed form to us:
By post, to Zurich Australia Limited Underwriting Department, Locked Bag 994, North Sydney NSW 2059, or
By email, as a scanned attachment, to [email protected], or
By fax, to 02 9995 3822.

Source: http://www.associatedmarine.co.nz/content/dam/australia/life_insurance/forms/life_form_asthma_questionnaire.pdf