Data Collection Form | Insurance | Life | Income
Butler & Butler Investment Services Pty Ltd
AFSL No. 229464

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Name: *

First

Last

Business Name (if applicable):

Date of Birth: *

Email: *

Phone: *

Home Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Sex: *— Select Choice —MaleFemalePrefer not to say

Occupation: *

Main Activities: *

List your main duties including any hazardous activities e.g maximum heights of work undertaken if above ground.

Years in this occupation: *

How long have you been working in this occupation.

Annual Gross Salary: *

Employer: *

Non Smoker / Smoker: *Please SelectNon SmokerSmoker

Height: *

Please enter your height.

Weight *

Please enter your weight.

Hazardous pastimes: *

List any relevant risky or hazardous pastimes, such as scuba, hang gliding, parachuting.

Current Insurances: *

Such as: Life, TPD or income protection insurance. Include Policy Number, Owner, Cover Type, Insured Value, Premium

Health Status: *

Can you please provide an overview of your current health status, including any existing medical conditions, ongoing treatments, or recent diagnoses?

Claims, have you ever claimed for benefits under any policy that you are interested in? *

• Yes
• No

Claims History: *

If you have had any claims, please list Date of Loss, Nature of Loss, Claimed Amount.

Superannuation details: *

Current Superannuation details, including, Owner, ESP Date, Cover Type, Insurance Cover, Current Value

Any other relevant info: *

I would like more information on: *

• Accident & Sickness Policy (General Insurance)
• Income Protection
• Life Insurance (Death)
• Total and Permanent Disability (TPD)

Your advisor is: *General Insurance Brokers (Sick & Accident)Brad Butler (Investment Services)Peter Thiele (Investment Services)Susan Baxter (Investment Services)

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By submitting this form I/We give consent for Butler & Butler Investment Services Pty Ltd to maintain a record of communications, identifying personal information including DOB, CRN, TFN, ABN and identification documents. I/We reserve the right to withhold information that does not relate to the specific investment or other life goals discussed.

Worth a read: Comparing – Income Protection and Sick & Accident policies