Client Declaration | NZ Insurance Services Limited

Which medication was prescribed

Were you asked to go for any further test or investigation

Reason for Hospitalisation

When was your most recent blood test done

Where it was done

Phone contact

Reason for this blood test and results

When was your most recent x-ray done

Where it was done

Reason and results for your most recent x-ray

Have you ever taken any medication

Names of all medication you have taken whether prescribed or not

Reason for taking this medication

List all the injuries you suffered

List all treatments and medications you received

Name of Doctor and hospital who provided the treatments and medication

List the names of all the specialist you have seen till to date

List any other conditions for which you have undergone or have been advised to undergo tests or investigations

Any other symptoms or signs which you are currently experiencing

Please indicate by writing YES or NO if you are currently suffering from, experiencing symptoms of or being treated for, or if you have ever suffered from, had symptoms of or had treatment for any of the following.

1. High blood pressure. Yes No

2. Abnormal or high cholesterol. Yes No

3. Respiratory or breathing disorder (e.g. asthma, lung disorder, bronchitis, emphysema, TB etc. Yes No

4. Liver disease or disorder (e.g. hepatitis, fatty liver or abnormal liver function tests etc. Yes No

5. Kidney disease or disorder (e.g. kidney stones, infections or abnormal renal function tests etc. Yes No

6. Urinary tract or bladder disorder. Yes No

7. Prostate disorders including abnormal PSA tests, or gynaecological disorders including abnormal PAP/cervical smears. Yes No

8. Breast disorders including lumps, cysts, discharge or abnormal mammograms or ultrasound scans. Yes No

9. Gastrointestinal tract, stomach or bowel disorder (e.g. ulcers, colitis, Cohn's disease etc. Yes No

10. Skin disorders (e.g. dermatitis, psoriasis, eczema, cysts, suspicious moles, lesions etc Yes No

11. Cancer or tumour. Yes No

12. Diabetes, abnormal blood sugar test or impaired glucose tolerance. Yes No

13. Thyroid disorder, gout or any other glandular condition. Yes No

14. Disorders of the ears, eyes (excluding long or short sightedness), nose or throat. Yes No

15. Epilepsy or seizures. Yes No

16. Blood disorders. Yes No

17. Varicose veins or haemorrhoids. Yes No

18. Mental or nervous disorders (e.g. depression, anxiety, stress, phobias Yes No

19. Chronic fatigue, fibromyalgia or chronic pain syndrome. Yes No

20. HIV, AIDS or antibodies to HIV, or potential exposure to HIV. Yes No

21. Sleep disorders (e.g. chronic insomnia or obstructive sleep apnoea etc. Yes No

22. Recurrent(1) or recent(2) dizziness or vertigo. Yes No

23. Heart disorder (e.g. heart attack, heart failure, heart valve disorders, cardiomyopathy, angina, endocarditis, chest pain etc. Yes No

24. Muscle, joint, spine, tendon or bone disorder or injury. Yes No

25. Arthritis or rheumatism. Yes No

26. Recent** ear, nose, throat, adenoid or tonsil infections (within the past 12 months). Yes No

27. Grommet insertion (or been advised that this may be required). Yes No

28. Oral surgery, impacted or interrupted teeth, gum infections or cysts within the past 12 months. Yes No

29. Irregular, heavy or painful menstrual bleeding or hormonal problems. Yes No

30. Blood in the urine, slow urinary stream, difficulties passing urine or sexual dysfunction. Yes No

31. Any neurological disorder (e.g. stroke, MS, paralysis, migraines or motor neurone disease Yes No

32. Any other conditions not listed above for which you have received treatment or therapy from any health provider, (including alternative practitioners), in the past five years (excluding minor ailments such as colds, flu and contraception). Yes No

33. Any other conditions not listed above for which you currently take medications, drugs, sedatives or over the counter preparations (excluding medications for minor ailments such as colds, flu and contraception). Yes No

34. Any other conditions not listed above for which you have undergone or have been advised to undergo tests or investigations, including genetic testing, in the past five years. Yes No

35. Any other symptoms or signs which you are currently experiencing or have experienced at any time in the past 12 months whether or not you have consulted a health professional regarding them. Yes No

36. Any dangerous hobbies (motor racing, sky diving , parachuting, boat racing etc) Yes No

Please initial at bottom to confirm you have read and understood this question

List all medical conditions your parents, brothers and sisters have or had, specify current age, date of death and date of diagnosis

Any other information you wish to provide which you think that might assist us to provide the best insurance cover.

hereby declare that the information provided on this form are true and correct.

BEFORE YOU SIGN THIS PLEASE READ AND INITIAL THE NEXT PAGE WHICH PROVIDES INFORMATION ON YOUR DUTY OF DISCLOSURE

DUTY OF DISCLOSURE

The DUTY OF DISCLOSURE means that you have a duty to disclose every information that you know ( or could reasonably beexpected to know ) in relation to all questions asked especially your medical history on the client declaration form. Our recommendations and the contract of life insurance will be based on the information you provide and failure to provide correct information may lead to your claim being declined and policy cancelled.

Clients Declaration Form

Clients Declaration Form

Please indicate by writing YES or NO if you are currently suffering from, experiencing symptoms of or being treated for, or if you have ever suffered from, had symptoms of or had treatment for any of the following.

Please initial at bottom to confirm you have read and understood this question

BEFORE YOU SIGN THIS PLEASE READ AND INITIAL THE NEXT PAGE WHICH PROVIDES INFORMATION ON YOUR DUTY OF DISCLOSURE

DUTY OF DISCLOSURE