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Affluens360 Wealth Management

Health Pre-Assessment Questionnaire

To provide us with a clear understanding of your health, lifestyle and existing insurance arrangements, please complete our health pre-assessment questionnaire (approx. 10 minutes).

This information allows us to have a more informed and productive discussion about your insurance needs from the outset. By identifying any potential premium loadings, policy exclusions, or special terms early in the process, we can provide more accurate advice and help minimise unexpected outcomes during the application stage.

Please answer each question honestly and as completely as possible. All information you provide will be handled with the strictest confidence in accordance with our privacy obligations.

Privacy: See consent section below

Questions? Email wealth@affluens360.com.au

 

Polling Form (#27)

1. Your Details

2. Physical Details & Lifestyle

3. Occupation & Income

4. Existing & Pending Insurance

To ensure we can provide accurate advice and minimise unexpected outcomes, please answer this section as thoroughly and honestly as possible.

 

5. Personal Medical History

For each question, let us know whether it relates to your current or past medical history. If applicable, please include the condition, approximate date, treatment undertaken, and your current health status.

6. Family Medical History

For immediate family only (parents, siblings). Please note any condition diagnosed before age 60.

 

7. Female-Specific Health (complete if applicable)

8. Hazardous Pursuits & Pastimes

Some description about this section

9. Overseas Travel & Residency

10. Additional Notes

11. Privacy, Consent & Declaration

Health information is sensitive information under the Privacy Act 1988. We collect it only with your consent, and only to help prepare an informed pre-assessment ahead of your Discovery meeting.

Important information: This document has been prepared by Affluens360 Wealth Management Pty Ltd ABN 46 152 465 462 for general information purposes only. It does not take into account your personal objectives, financial situation or individual needs. You should seek independent professional advice before acting. Affluens360 Wealth Management Pty Ltd ABN 46 152 465 462 is a Corporate Authorised Representative (No. 410582) of Advisory Circle Pty Ltd ABN 21 629 143 460 AFSL 513052. This questionnaire is a pre-assessment tool only, is not an application for insurance, and does not bind or guarantee terms with any insurer. All insurance recommendations remain subject to formal underwriting and require Authorised Representative approval before being provided to you as personal advice.
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Address

Suite 302,7-9 Irvine Place,
Bella Vista NSW 2153

Connect

1300 038 746
info@affluens360.com.au

 

Disclaimer: This website does not take into account any of your objectives, personal circumstances, financial situations or needs, and you should consider the appropriateness of this information in light of your own circumstances. If the content relates to the acquisition of a financial product, you should obtain and read a copy of the PDS/Prospectus relating to that product before making any decision. Affluens360 Wealth Management Pty Ltd, ABN 46 152 465 462, is an Authorised Representative of Advisory Circle Pty Ltd ABN 21 629 143 460 AFSL 513052. Note: Accounting, Tax & Business Planning, Legal, Buyers Agent Solution, Finance & Lending Services are provided independently of Advisory Circle Pty Ltd.

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