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. www.metlife.com.au Asthma Questionnaire page 2 of 5 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 www.metlife.com.au Asthma Questionnaire page 3 of 5 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 www.metlife.com.au Asthma Questionnaire page 4 of 5 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. www.metlife.com.au Asthma Questionnaire page 5 of 5
CEREXAGRI B.V INSTRUÇÕES DE USO: Equipamentos: INFORMAÇÕES SOBRE OS PROCEDIMENTOS PARA A DEVOLUÇÃO, - Não desentupa bicos, orifícios e válvulas com a boca. - Fique atento ao período de vida útil dos filtros, seguindo corretamente as Sintomas e Exposição Respiratória: Tankhoofd 10 - 3196 KE Vondelingenplaat, Rotterdam - HolandaO produto deverá ser aplicado em
I General Background II Items not fit to local practice III Items not well-defined or questionable IV Hot Issues V Future – PALS The topics selected for discussion are based on 3 years of feedback from participants in PALS Provider Courses in Japan. Localization issues, by definition, are different for each country. We hope to encourage a free exchange of information to identify issues of import