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Insurance Questionnaire

MM slash DD slash YYYY
MM slash DD slash YYYY
Home Address(Required)
Are you an Australian citizen with a valid Australian Medicare card, or do you hold a visa allowing you live, work or study in Australia?(Required)
Excess required?(Required)
Cancellation cover amount required?(Required)
Do you require additional luggage cover?(Required)
Do you require cover for snow skiing, snowboarding or snowmobiling?(Required)
Are you travelling for 2 or more nights on a cruise on the sea or ocean, or on a river outside of Australia?(Required)
Do you require Adventure Activity cover?(Required)
Do you require Motorcycle/Moped Riding cover?(Required)
In the last 12 months, has any traveller been hospitalised or treated in the emergency department, seen a specialist, or had day surgery?(Required)
Is any traveller: •taking prescription or over the counter medication to treat, control or prevent their condition? e.g. insulin for diabetes, aspirin for strokes, Paracetamol for back pain •having regular check-ups? •under investigation, waiting on a diagnosis or surgery?(Required)
Has any traveller got a chronic, ongoing or reoccurring condition? e.g. arthritis or back pain(Required)
Has any traveller ever had a medical condition or required surgery involving any of the following? Kidneys, Liver •Cancer (even if in remission) •Joint, back or spine •Brain e.g. Dementia, Epilepsy, head injury, Tumours •Any heart-related condition e.g. Angina, bypass surgery, heart attack, irregular heart rhythms, stents •Strokes e.g. clots, Deep Vein Thrombosis, mini strokes, Pulmonary Embolism •Respiratory system e.g. Chronic Bronchitis, COPD, Emphysema(Required)
If any travellers are pregnant: Have there been complications with this or a previous pregnancy? Is it a multiple pregnancy e.g.twins or triplets ? Was the conception medically assisted? e.g. using assisted fertility treatment including hormone therapies or IVF (Pregnancy cover is limited to unexpected complications up to the 24th week. Childbirth or care of a new-born is not covered)(Required)
Is any traveller experiencing any signs or symptoms where a medical diagnosis has not been sought? e.g. chest pain, shortness of breath, a persistent cough or unexplained bleeding.(Required)

If you ticked YES to any of these questions, please complete a medical assessment form and insert the number below

Click here for Medical Assessment Form

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