Vivid Advisers

Name*

First Last

Email*

If you are getting advice as a couple, please complete this questionnaire individually for each of you.

Date of Birth*

DD

MM

YYYY

Height*

Weight*

Main Occupation*

Employer*

Start date at this Employer*

DD

MM

YYYY

Hours worked per week*

Annual Gross Salary*

Nature of duties at work?*

How long have you been in this occupation? (include same occupation with different employers)*

Less than 6 months
6-12 months
1-3 years
More than 3 years

Do you have a second occupation?*

Yes
No

How many hours per week?

Have you ever been declared bankrupt, or have any entities owned or controlled by you been placed under administration, receivership or into liquidation?*

Yes
No

Any planned changes to your occupation in the next 12 months?*

Yes
No

If yes, please explain?

Does your occupation involve any of the following?*

Lifting or moving heavy goods without the use of machinery?
Working underground?
Working offshore and/or underwater?
Working at heights over 10 meters
Working with chemicals, gases or radioactive substance?
Working with explosives and/or high voltage electricity?
None of the above

Have you smoked tobacco, cigars or a pipe, or any other substance within the past 12 months, or used nicotine replacement treatment in the last 3 months?*

Yes
No

Do you currently engage in, or intend to engage in any of the following pursuits, pastimes or activities?

Any type of football (including rugby, touch, soccer, Aussie Rules)?*

Yes
No

If yes, provide details:*

Motor sports (including trail bike riding)*

Yes
No

If yes, provide details:*

Recreational activites involving heights (including rock climbing, abseiling, mountaineering, parachuting, hand-gliding)?*

Yes
No

If yes, provide details:*

Combat sports (including boxing, martial arts, mixed martial arts)?*

Yes
No

If yes, provide details:*

Underwater recreational activities (eg scuba-diving)?*

Yes
No

If yes, provide details:*

Water Sports (including water-sking, canyoning)?*

Yes
No

If yes, provide details:*

Underground activities (eg caving)?*

Yes
No

If yes, provide details:*

Flying (not including as a fare-paying passenger)?*

Yes
No

If yes, provide details:*

Skiing, snowboarding or skating?*

Yes
No

If yes, provide details:*

Any other competitive sport?*

Yes
No

If yes, provide details:*

Have any of your BLOOD-RELATED parents, brothers or sisters been diagnosed with or suffered from any hereditary conditions (eg cancer, heart attack, diabetes, Alzheimer's)?*

Yes
No

If yes, provide details:*

Insurance Questionnaire