Personal
Risk Insurance Profile
Private and confidential
Name Client 1
Name Client 2
June 2013
Page 1 of 17
Section 1 - Administration
Personal details
Client 1
Client 2
Title
Given names
Surname
Preferred name
Sex
 Male
 Female
 Male
 Female
Date of birth
Marital status
 Single  Defacto
 Engaged  Single  Defacto
 Engaged
 Married  Separated  Divorced  Married  Separated  Divorced
 Widowed
 Widowed
Date of marriage
Previous marriage(s)
 Yes
Details:
 No
 Yes
Details:
 No
Australian tax resident
 Yes
 No
 Yes
 No
 Yes
Details:
 No
 Yes
Details:
 No
Tax File Number
Private health insurance
Contact details
Client 1
Client 2
 Same as Client 1
 Other:
 Same as Client 1
 Other:
Home address
 Same as above
 Other:
Postal address
Home phone
Work phone
Mobile
Fax
Email
Children and other dependant details
Name
Date of Birth
Living at Home?
Financially
dependant?
(until age …)
Special Needs?
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Page 2 of 17
Professional contacts
Name
Relationship
(Accountant,
Solicitor)
Company
Phone
no.
Address
Contact
 Yes  No
 Yes  No
 Yes  No
 Yes  No
Estate planning details
Client 1
Client 2
 Yes
 No
 Yes
 No
Do you have a testamentary
trust?
 Yes
 No
 Yes
 No
Do you have an enduring
power of attorney?
 Yes
 No
 Yes
 No
Do you have an enduring
power of guardianship?
 Yes
 No
 Yes
 No
Have you appointed a
guardian for your children?
 Yes
 No
 Yes
 No
Do you have a Will?
If Yes:
when was it last
reviewed?
Additional information
Page 3 of 17
Superannuation details
Fund 1
Fund 2
Fund 3
Fund 4
Fund name
Type
Owner
Policy number
Current value
Existing adviser?
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
Would you like me to take
over policy responsibility?
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
Insurance details
Policy 1
Policy 2
Policy 3
Policy 4
Life insured
Insurer/product
Policy number
Policy owner
Within Super?
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
Type of insurance
Benefit amount
Waiting and benefit period
Loadings or exclusions?
Details:
Premium and frequency
Beneficiary details
How insurance obtained?
Existing adviser? Who?
Would you like me to take
over policy responsibility?
Additional information
Page 4 of 17
Underwriting information
Employment details
Client 1
Client 2












Occupation/position
Duties
Education/trade
qualifications
Industry
Employment status
Employed F/T
 Employed P/T
Employed casual  Self employed
Contractor
 Home duties
Not working (ill health)
Retired
 Unemployed
Other
Employed F/T
 Employed P/T
Employed casual  Self employed
Contractor
 Home duties
Not working (ill health)
Retired
 Unemployed
Other
Business structure
Employer name
Employment start date
Years in current occupation
Is there likely to be a change  Yes  No
in employment status?
Details:
 Yes  No
Details:
Accrued leave (annual, sick,
long service leave)
Health details
Client 1
Client 2
What is your current state of
health?
 Excellent
 Average
 Good
 Poor
 Excellent
 Average
 Good
 Poor
Height and weight
Do you smoke?
 Yes
 No
 Yes
 No
Are you taking or have you
been on any prescribed
medication? (If yes, provide
details eg. description,
condition, frequency and
dosage)
 Yes  No
Details:
 Yes  No
Details:
Client 1
Client 2
Family history
Previous insurance claims
(income protection, workers
comp etc)
Hazardous pursuits details
Do you have any special
interests (eg. scuba diving,
sky diving, car racing)?
Additional information
Page 5 of 17
Section 2 – Asset, liabilities, income, expenditure
Personal
Non-revenue producing assets
Capital Value
($)
Debt
($)
Residence, principal
Residence, other
Motor vehicles
Leisure items (boats, jet-skis, etc)
Collections (art, wine, etc)
Other property
Revenue
generated ($)
Retention
costs ($)
Retention time
(S/M/L)
Ownership
Intended
ownership
Retention
costs ($)
Retention time
(S/M/L)
Ownership
Intended
ownership
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
Nil
TOTAL
Revenue producing assets
Capital Value
($)
Debt
($)
Revenue
received ($)
Personal earnings – client 1
Personal earnings – client 2
Investment property 1
Investment property 2
Investment property 3
Equities
Savings accounts
Term deposits
Trusts
Superannuation contribution
Government benefits (Centrelink, DVA,
etc)
Maintenance payments (receipt of)
TOTAL
Page 6 of 17
Amount
($)
Current expenditure
Duration
(Years)
Living expenses
Credit card repayments
Taxation provision
Bank overdraft interest
Insurance premiums - life
Insurance premiums - general
Insurance premiums - health
School fees
TOTAL
Business
Business expenses
Client 1 (pa)
Client 2 (pa)
Property expenses:
 rent
 mortgage repayments
 property rates and taxes
Equipment expenses and lease costs
Business vehicle costs:
 lease costs
 registration
Utilities:
 electricity
 heating
 water
 gas
 telephone etc
Maintenance costs:
 repairs
 maintenance costs
 cleaning and laundry
Professional fees:
 accountant
 solicitor
 adviser fees
Business insurance premiums
Depreciation of office equipment and premises
Salaries and other costs of non-revenue producing
staff
Other:
Percentage of expenses that would continue over
a 12 month period if the client was unable to work
Percentage of expenses for which client is
responsible
Percentage of revenue that would continue over a
12 month period if the client was unable to work
Page 7 of 17
Section 3 – Strategies, future plans and preferences
Strategies - general
General
Agreed scope of advice
Client 1
Client 2










All
 Term
TPD
 Trauma
Income Protection
Business expenses
Other
All
 Term
TPD
 Trauma
Income Protection
Business expenses
Other
Advice limitations
Strategies - product specific
Term insurance
Client 1
Client 2
Client 1
Client 2
Client 1
Client 2
Death: reduce debt, replace income,
estate equalisation, charitable bequest
Terminal Illness: reduce debt, medical
treatment, travel
TPD insurance
Total and Permanent disability: capital
needs, revenue needs
Own or Any Occupation definition
Trauma insurance
Medical & rehabilitation
Lifestyle changes: repay debt, pre-fund
school fees, 25% income protection
shortfall, holiday, top-up super, early
retirement
Basic or comprehensive
Other insured events
Page 8 of 17
Income protection



Client 1
Client 2
Client 1
Client 2
Client 1
Client 2
core expenditure & super
contributions
discretionary expenditure
assets & investment income
Duration of self insurance (waiting
period)
Agreed value or indemnity
Ancillary benefits: family focus,
rehabilitation focus, zero waiting period
Optional benefits: inflation protection,
maximum cover, accident cover
Business expenses

fixed expenses
Family strategy
Potential future action
Grandparents
Parents
Children
Brothers/Sisters
Grandchildren
Influencing factors?
Disputes, irresponsibility’s,
idiosyncrasies.
Page 9 of 17
Future plans
Potential future action
Client 1
Client 2
Change of occupation or level of
earnings
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
Change in work hours
Planned leave: long-service, maternity,
paternity, sabbatical leave, unpaid, etc
Living, working or travelling overseas
Expected birth or adoption of a
child/grandchild
Change in level of debt
Change in marital status
Change in educational status of
dependants
Becoming a carer
Additional information
Page 10 of 17
Preferences
Filter
Details
Insurer choice
 market intelligence
 personal experience
 3rd party experience
 personal reasons
Insurance placement
 flexibility in policy choice
 duplicate policy fee
 duplicate claims
requirements
Adviser relationship and
experience
 influence on u/w, admin
& claims decisions
Price sensitivity
 additional benefits
 additional features
 target segment
 sustainability
 claims experience
Personal circumstances
 availability for medical
requirements
Budget
Policy duration
 short or longer term
Underwriting factors
 health issues, treatment?
 Hazardous pursuits
Page 11 of 17
Privacy Statement
RI Advice Group Pty Ltd (ABN 23 001 774 125) is committed to ensuring the confidentiality and security of your
personal information.
In order to manage and administer our financial planning services, it may be necessary for us to disclose your
personal information to third parties. By not consenting to this disclosure we may not be able to provide you with
financial planning services. The parties to whom we may disclose your personal information include:




financial institutions for the provision of financial products such as investments, superannuation and life
insurance
RI Advice Group Pty Ltd Representatives for the purpose of managing your investments and financial products
organisations undertaking compliance review of our financial advisers or review of the accuracy and
completeness of our information
organisations providing mailing services, maintenance of our information technology systems and printing of
our standard documents and correspondence.
We will only disclose your personal information to these organisations to enable them to undertake specified
management and administration services. RI Advice Group will not disclose your information for any other purpose
unless requested by you.
In some cases, it may be necessary to share your personal information with other members of the group for the
provision of certain services such as information technology or for the provision of financial products which you
have selected.
Where you wish to authorise any other parties to act on your behalf, to receive information and/or undertake
transactions, please notify us in writing.
We may send you further information from time to time about RI Advice financial planning services. You may elect
to stop receiving such information at any time by contacting RI Advice on 1800 738 473 or by visiting our website
at www.retireinvest.com.au or www.riadvice.com.au. You may at any time advise us that you wish to recommence
receiving RI Advice information.
You may request access to information held by us by telephoning 1800 738 473.
Warning – important notice for you
Before making any recommendations to you, your adviser must have reasonable grounds on which to base those
recommendations. This requires your adviser to ask you about your objectives, financial situation and particular
needs. This form is designed to gather that information. You are not obliged to provide all information requested
however failure to supply full and accurate information may result in inappropriate advice or the wrong advice
being provided. If you are unsure of the answer to any question please leave it blank until you have discussed it
with your adviser.
Page 12 of 17
Client Declaration and Consent
I/I/We declare that:
Personal Insurance Profile Declaration
 I/We acknowledge that information provided in the Personal Insurance Profile is complete and accurate.
 I/We understand that it will form the basis of any Statement of Advice that will be delivered by RI Advice to
achieve my/our financial needs and objectives as detailed in this document.
 I/We understand the warnings provided to me/us in relation to the areas in which I/we have chosen not to
receive any advice.
Provision of FSG Declaration
 I/We confirm that I/we have received a copy of the RI Advice Financial Services Guide and its contents have
been explained to me/us by the financial adviser.
Privacy Declaration
 I/We acknowledge that I/we have read the Privacy Statement contained within the Personal and Financial
Profile.
 I/We understand that unless we consent to the collection, use and disclosure of our personal information as
identified in the Privacy Statement, RI Advice will not be able to deliver the relevant financial planning and
advice services or manage our investment portfolio.
Third Party Declaration
 For the provision of obtaining financial advice, we authorise the collection of information from any relevant
third party such as: Australian Taxation Office; Centrelink; Department of Veterans’ Affairs; fund managers; my
solicitor; my accountant; etc.
Tax File Number Declaration
 I/We give permission for you to retain our tax file number(s), as provided within the ‘Personal Details’ section
of this document, and for it to be forwarded to financial institutions as requested or as necessary.
Marketing Declaration
 I/We accept that RI Advice may send us information about its services from time to time. I/We understand that
we must notify you of our decision not to receive further information by contacting you directly.
Client 1: Name
Signed
Date
Client 2: Name
Signed
Date
Adviser Declaration and Consent
I declare that:

The client(s) has been provided with a copy of the Financial Services Guide (FSG) before advisory services
were provided and its contents have been explained to the client(s).
Adviser: Name
Signed
Date
Page 13 of 17
Declaration
For existing clients: Confirmation that Personal Risk Insurance Profile is current.
I/We confirm that previous details collected in this Personal Risk Insurance Profile remain unchanged or that
previous details collected in this Personal Risk Insurance Profile have been adjusted to reflect our personal and
financial circumstances.
Date
/
/
/
/
/
Client 1 signature
Client 2 signature
/
/
/
/
/
Additional information
Page 14 of 17
Letter of Engagement
Date:
Dear:
I would like to thank you for providing us with the opportunity of discussing your risk insurance needs with you. My
next step is to provide you with a Statement of Advice.
By signing this ‘Letter of Engagement’ you will:

authorise me to prepare a Statement of Advice on your behalf, which will provide advice in the following areas:






Life insurance
Total and Permanent Disability (TPD) insurance
Trauma insurance
Income protection insurance
Business expenses insurance





Life and TPD insurance through Superannuation
Key person insurance
Business succession insurance
Other:
Other:
agree to pay the cost of the preparation of the Statement of Advice which is $
(inclusive of GST),
payable to RI Advice Group Pty Ltd prior to the presentation of your Statement of Advice or other arrangement
as indicated below:.
Please note, the ‘Statement of Advice preparation fee’, as well as any other fees or commissions that RI Advice
will receive, will be clearly set out in the Statement of Advice.
The Statement of Advice will be based on my understanding of personal circumstances and needs and objectives,
as documented within the Personal Insurance Profile, which you have completed and signed to acknowledge that
the information is complete and accurate.
Client Declaration


I/We acknowledge and agree with the terms and conditions of engagement included in this document and
request that you proceed on the basis of these terms and conditions. In particular, we have read and
understood the areas for which we seek advice outlined above, and accept that our financial adviser will
prepare a Statement of Advice based on these areas.
I/We further understand and agree that should we decide not to proceed with recommendations made in the
Statement of Advice that we will still need to pay the above fee for the preparation of the Statement of Advice.
Yours sincerely,
Authorised Representative
RI Advice Pty Limited
Client 1: Name
Signed
Date
Client 2: Name
Signed
Date
Page 15 of 17
Authority to provide information
To:
Client (s)
Address
Suburb
Date of birth
State
Postcode
Investor number(s)
I/we authorise my Financial Adviser,
who is a representative of RI Advice Group Pty Ltd (ABN 23 001 774 125) and whose signature appears below, to
request and receive any information during the period set out below in relation to
held by me/us.
Please accept a photocopy of this letter as authority, as the original will remain with RI Advice.
Should you require further information, I/we can be contacted on
This authority is valid for a period of 120 days from the date below.
Client 1
Client 2
Signature
Signature
Date
Date
Financial Adviser
Signature
Financial Adviser name
Date
Financial Adviser address
RI Advice Group Pty Ltd | ABN 23 001 774 125 AFSL 238429 Australian Credit Licence 238429
Page 16 of 17
Adviser notes
Adviser name
Date
FSG version number
Date FSG provided
Supplementary FSG Version Number
Date Supplementary FSG provided
Page 17 of 17