Insurance Assessment Form NurseWise Insurance Quote Thank you for taking the time to evaluate yourself. Please thoughtfully and accurately fill in the information below. Your Contact DetailsYour Name* First Last Date of Birth* DD dash MM dash YYYY Email Address* Phone Number*Are you looking for:* Professional Indemnity & Legal Expenses Personal Life, Total Permanent Disablement, Income Protection or Trauma Cover Your Insurance RequirementsLife InsuranceHow much life insurance would you like? Life insurance pays your beneficiaries a tax-free lump sum in the event of your death.Disability InsuranceHow much disability insurance would you like? Permanent Disability insurance provides a tax-free lump sum in the event of your permanent disablement.Income InsuranceHow much of your income would you like to insure? ($per annum) You can insure up to 75% of your income. If you are unable to work due to injury or illness an Income insurance benefit can provide you with a monthly income, ensuring you can focus on your recover. Insurance premiums are generally tax-deductible.Critical Illness InsuranceHow much Critical Illness would you like? Critical Illness insurance insurance can provide you with a tax-free lump sum to assist with the cost of living and care in the event that you are diagnosed with a critical illness (most common being cancers, heart attacks or disease, strokes).Your HealthAre you a smoker?* Yes No Have you ever suffered from any of the following? High blood pressure High cholesterol Cancer (of any kind) Chest pains, heart murmurs or stroke Abnormal blood sugar levels Depression or anxiety Back or neck complaints Skin disorders (such as eczema, psoriasis) If you ticked any of the conditions above, please provide more information (who, when, what)Prior to the age of 60, have any of your immediate family (parents, brother or sister) ever suffered from heart disease, cancer, diabetes, stroke or any mental disorder?If the answer is YES, please provide more information (who, when, what)Is there anything else you would like to tell us?