Insurance Questionnaire Funnel Form

Step 1: Personal & Financial Information

Full Name

Phone Number

Email Address

Age

What is your current annual income?

Do you have any dependents (spouse, children, parents)?

Yes

No

Do you have a mortgage or any other major debts? If yes, how much?

How long could you survive financially if you were unable to work? (in months)

What is your occupation? Do you work in a high-risk industry?

Do you have any pre-existing medical conditions?

Yes

No

Do you smoke or drink alcohol regularly?

Yes

No

Do you want insurance inside your superannuation, outside, or a mix of both?

What level of private health coverage do you need (hospital, extras, or both)?

How much are you willing to spend monthly on insurance premiums?

Do you have existing insurance policies? If so, what type and coverage amounts?

Would you prefer a lump sum payout or ongoing income if something happens to you?

Please review your information before submitting.

I acknowledge that I have read and understood the disclaimer.