RISK INSURANCE
FACT FINDER
Address: Level 1, 65 Palmerston Crescent
South Melbourne VIC 3205
Post: PO Box 438 North Melbourne VIC 3051
Tel: 03 9328 3900 Fax: 03 9328 4031
PERSONAL DETAILS:
Client
Title
Surname
Given Names
Gender
 Male
Spouse/Partner
 Female
 Male
 Female
Home Address
Business Address
Phone No.
Fax No.
Mobile Phone No.
Email Address
Date of Birth
Smoker or Non-Smoker
Date Ceased Smoking
(if applicable)
General State of Health
 Good  Average  Poor
 Good  Average  Poor
Occupation
Duties
Date Commenced
Employee or Self Employed
Business Name
Age of Dependant Children
IMPORTANT INFORMATION
It is a requirement that an adviser provide you with a recommendation that is in your best interests. To do so, there needs
to be a reasonable basis for the advice. This document helps collate your information to enable a recommendation that is
suitable and relevant to yourself.
Where you have not provided full information, the recommendations derived from this document may not be suitable to
your situation. Prior to proceeding, please read the relevant Product Disclosure Statement (PDS).
Your adviser is an Authorised Representative of Synchronised Business Services Pty Ltd trading as Synchron.
ABN 33 007 207 650
Life Insurance Broker – Australian Financial Services Licence No. 243313
www.synchron.net.au
SYNCHRONISED BUSINESS SERVICES PTY LTD ABN 33 007 207 650
Securing your financial future
Life Insurance Broker – Australian Financial Services Licence No. 243313
www. synchron.net.au
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FINANCIAL INFORMATION:
IMMEDIATE NEEDS TO BE COVERED IN THE EVENT OF YOUR DEATH OR DISABLEMENT:
Client
Spouse/Partner
Home Mortgage
Mortgage on other Real
Estate
Other Debts (eg Car,
Overdraft, Credit Cards)
Final Expenses (eg Funeral,
Legal, Medical)
Emergency Fund
Business Liabilities (eg
Personal Guarantees)
Tax Liabilities
Education Funding – annual
fees and length of time
ONGOING INCOME REQUIREMENTS OF SPOUSE/FAMILY IN THE EVENT OF YOUR DEATH OR DISABLEMENT (as
calculated from the Lump Sum Ready Reckoner on page 4):
Annual Income
Number of Years Required
ASSETS YOUR FAMILY COULD LIQUIDATE IN THE EVENT OF YOUR DEATH OR DISABLEMENT:
Existing Life Insurance
Superannuation
Investments
Superannuation Life Cover
Name of SMSF (if
applicable)
Name of SMSF Trustees (if
applicable)
SMSF insurance details (if
applicable)
Investments (as listed on
Page 3)
Cash Reserves
Business Assets
Other
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EXISTING INCOME PROTECTION INSURANCE:
Client
Spouse/Partner
Monthly Benefit
Benefit Period & Waiting
Period
Current Premium
SELF EMPLOYED
Business Name:
Business Structure:
Business Address:
Telephone:
Fax:
Mobile:
Email:
Has the business borrowed
money?
Have you given any
personal guarantees for
business loans?
Has the loan been secured
against your home?
Tell me about your business?
How did you get started in this business?
What is your plan to exit the business?
Do you have a succession plan?
Have all the documents been executed and are they current?
What funding mechanism have you put in place?
What method have you used to lock in your key people?
How have you preserved the working capital of the business?
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PERSONAL CONSIDERATIONS:
Client
1. Will your spouse/partner want to continue or commence
work in the event of your death or total & permanent
disablement?
Spouse/Partner
 No
 Yes
 No
 Yes
Death
 No
 Yes
 No
 Yes
Total & Permanent Disablement
 No
 Yes
 No
 Yes
Traumatic Illness or Condition (Cancer, Stroke, Heart Attack
etc)
 No
 Yes
 No
 Yes
Loss of Income due to Disablement
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
Would you like to review your General Insurances (Business
and Personal)?
 No
 Yes
 No
 Yes
Do you have an up to date Will?
 No
 Yes
 No
 Yes
If no Will, would you like to be referred to a Solicitor?
 No
 Yes
 No
 Yes
Are you interested in insuring against the following events?
Do you anticipate receiving any financial inheritance?
Give Details.
INCOME DETAILS:
1. What is your gross annual income from personal
exertion?
$
$
2. What is your gross earnings from investments?
$
$
3. Any other income or earnings?
$
$
4. Sick Leave/Long Service Leave entitlements through your employer?
CURRENT INVESTMENTS:
Please include ALL investments owned by you or your spouse/partner (singly or jointly).
What is the total value of all non-superannuation investments?
INVESTMENT
VALUE
Shares
$
Property
$
Insurance Bonds
$
Unit Trusts
$
Other
$
Total $
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LUMP SUM READY RECKONER
The purpose of this table is to help you calculate the lump sum required to generate a nominated level of
income to your spouse/family following your death. This process requires you to ask the question “If I died
yesterday, what would my family’s future income requirements be as from today?”
The future income needs often represent the largest component of a person’s life insurance program. It depends
heavily on your present situation as well as the assumptions you make. For instance, in your absence:






would your spouse and family need income support?
would he or she be able to continue working? If so, at the same level?
if your spouse is not currently working, would you expect he or she to find suitable employment?
should you allow for housekeeping/childcare costs if your spouse became employed?
will your children be educated privately? If so, at what schools and for how long?
what level of income would be required? Living expenses, education costs etc.
Income Stream Calculator
Real Rate of Return per annum
No. of Years
Income
Required
5
10
15
20
25
30
35
40
3%
4%
5%
6%
7%
Capital Sum required to produce an annual income of $10,000
$
$
$
$
$
47,171
46,299
45,460
44,651
43,872
87,861
84,353
81,078
78,017
75,152
122,961
115,631
108,986
102,950
97,455
153,238
141,339
130,853
121,581
113,356
179,355
162,470
147,986
135,504
124,693
201,885
179,837
161,411
145,907
132,777
221,318
194,112
171,929
153,681
138,540
238,082
205,845
180,170
159,491
142,649
Example:
You have determined that your family would have ongoing income requirements of $40,000 per annum in the
event of your death. The income would need to be maintained for 20 years and you estimate a real rate of
return of 5% can be achieved on the capital invested. Note that using the figures in the above table, the capital
would be exhausted at the end of the period.
Income required:
Number of years income required:
Real rate of return:
Calculation:
$40,000 per annum
20
5%
$130,853 (for every $10,000 of income)
x 4 = $523,412
This amount should be carried across to your Life Insurance calculation sheet.
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HEALTH STATEMENT
Client
Spouse/Partner
What is your height and
weight?
Do you smoke? If yes, what
is your daily quantity?
Do you drink alcohol? If yes,
what is your weekly
quantity?
Any abnormality affecting
eyesight, hearing, speech or
physical mobility?
Have you ever suffered from:
High blood pressure
High cholesterol
Chest pain
Heart attack
Stroke
Cancer/Tumour or lump of
any kind
Mental or nervous disorder
including stress, anxiety or
depression
Asthma or any lung or
repertory disorder
Back or neck pain
Shoulder or knee problems
Broken bones
Repetitive strain injury
Gout
Muscle or Joint Paint
Diabetes
Epilepsy
Multiple Sclerosis
Hepatitis
Any other sickness, injury or
physical impairment
Have a family history of any
of the above or any other
hereditary diseases?
Details:
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PROFESSIONAL CONTACTS:
Solicitor
Phone:
Accountant
Phone:
Other
Phone:
A C K N O W L E D G E M E N T:
I acknowledge that the information I have provided is accurate and relevant to my personal situation. Where
full and complete information has not been provided, I acknowledge that the recommendations derived may
not be appropriate to my situation and needs.
I authorise my adviser to retain and use my Tax File Number (TFN) for the provision of financial services advice
only. Where the TFN is no longer required, it will be destroyed or de-identified.
I authorise my adviser to contact me regarding financial planning matters that may interest me or be relevant
to my situation. A copy of the Synchron Privacy Act is available to me at any time online at
www.synchron.net.au or from my adviser.
I acknowledge that my identification information may be required before any financial services or products
are applied for in line with the Anti-Money Laundering and Counter Terrorism Financing Act. My information
will be provided to the particular product issuer(s).
Signature of Client
Date:
/
/
Signature of Spouse/Partner
Date:
/
/
Date:
/
/
Adviser’s Name
Signature of Adviser
NOTES:
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