Metlife.com.au

Asthma Questionnaire
Duty of Disclosure (Insurance Contracts Act 1984)
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, that 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 vary or reinstate a contract of life insurance.
Your duty, 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 the insurer’s business as an insurer, ought to know; OR  where which compliance with your duty is waived by the insurer.
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 three 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 three 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.
Please note: Your Duty of Disclosure continues until a policy has been issued.
Privacy Statement
MetLife is subject to the National Privacy Principles under the Privacy Act 1988 and has a Privacy Statement that explains how
we handle the information about you that we collect. For a copy of the MetLife Privacy Statement please refer to the Product
Disclosure Statement which was provided to you or contact MetLife Customer Service on 1300 555 625.
MetLife Insurance Limited
ABN 75 004 274 882
AFSL No. 238096
MetLife Insurance Limited
ABN 75 004 274 882
AFSL No. 238096
Level 9, 2 Park Street, Sydney NSW 2000
GPO Box 4528 Sydney NSW 2001
Asthma Questionnaire
To be completed by the proposed person to be insured.
If space is insufficient, please attach an extra sheet of paper.
Please complete the questionnaire in BLACK ink pen only.
Any changes made to this questionnaire to be initialled by the proposed person to be insured.
Personal Details
Date of Birth:
D D / M M / Y Y
Group Scheme Name / Number:
OR Individual Policy Number:
Note: You will have a Group Scheme Name/Number if your application for insurance is through your Superannuation fund OR Employer, otherwise you will have an Individual Policy Number.
Questionnaire
For the purposes of this questionnaire, please read “symptoms” to refer to whatever you experience as asthma. This
refers to slight wheezing, chest tightness or coughing or full blown attacks. Please read and answer all questions
this way.
1 When did you first experience symptoms of asthma?
D D / M M / Y Y
2 How many times a year do you have symptoms?
3 What is the average duration of symptoms?
4 What was the date of the last time you experienced symptoms?
D D / M M / Y Y
5 Are the symptoms of asthma you experience severe enough to hinder your
regular work or social activities?
If “Yes”, please give full details.
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Questionnaire (cont.)
6 Have you ever been hospitalised, had specialist investigations, advice or treatment for asthma? Yes No
If “Yes”, please give details.
7 Do you suffer from shortness of breath, coughing, and/or wheezing in the intervals between attacks? Yes No
If “Yes”, please give full details.
8 Do attacks occur in conjunction with flu like episodes (as opposed to independent of other illness)? Yes No
9 When does your asthma mainly occur?
Mostly during the day
At any particular time of the year?
Please provide full details.
10 Are you being treated for asthma at present? (include both preventative medication and
medication for relief of acute exacerbation)
If “Yes”, please list the names of all medications used, and how they are used (for e.g. Serevent Inhaler, 1 puff twice daily).
Medication
Frequency
11 Have you at any time been treated with: (Please tick all that apply).
Prednisone
Prednisolone
Other corticosteroid
If “Yes” to any, please give full details.
12 Do you smoke, or have you in the last twelve months smoked tobacco or any other substance?
If “Yes”, please advise the quantity smoked per day and the actual substance and form (e.g. tobacco as cigarettes).
Substance and Form
Average quantity per day
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Questionnaire (cont.)
13 Please list all medication, not previously mentioned in this questionnaire, that you are taking regularly or
intermittently whether for this or any other condition or illness.
14 Have you ever had regular absences from work or been absent from work or restricted in your
lifestyle for more than one month at a time as a result of injury or illness?
If “Yes”, please give details including dates & duration.
Injury/Illness
15 Please provide the full name and address of all General Practitioners and Specialists who currently treat, and have
previously treated you for this condition and any other conditions.
Last Consultation
16 Please provide any additional information that may help assess your application for insurance.
MetLife Medical Authority
MetLife Insurance Limited (MetLife) is considering my application for insurance and I hereby authorise any medical
practitioner, hospital, clinic or other person (including a life insurance company or underwriter) to disclose to MetLife or
any third party engaged by MetLife full details of my health and medical history. A photocopy of this Authority should be
accepted as my personal authority.
Date of Birth:
D D / M M / Y Y
Address:
Postcode:
Signature:
D D / M M / Y Y
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Declaration
I declare that the answers I have given are to the best of my knowledge, true and complete and that I have not withheld
any material information that may influence the assessment or acceptance of my application. I acknowledge that this
questionnaire is part of the application for life Insurance and that failure to disclose any material fact known to me may
invalidate the contract.
Signature of the person whose life is to be insured:
D D / M M / Y Y
Products are offered by MetLife Insurance Limited, which is an affiliate of MetLife, Inc. (Incorporated in the USA) and operates under the “MetLife” brand. None of the obligations of MetLife Insurance Limited are guaranteed by MetLife, Inc. or any other member of the MetLife group. Prepared February 2008.
PEANUTS United Feature Syndicate, Inc.
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Asthma Questionnaire
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Source: http://www.metlife.com.au/au/assets/documents/systemic/MET_Asthma_web.pdf