About this template
This Financial Planning Insurance Pre-Assessment Google Form Template is designed for insurance brokers, financial advisors, and underwriting teams to efficiently gather critical risk data from prospective clients before formal application submission. Collecting comprehensive details upfront—such as personal background, medical history, occupation hazards, and lifestyle factors—saves valuable time and accelerates the underwriting process.
The form covers all essential pre-assessment categories including height and weight, nicotine and alcohol use, hazardous sports, family medical history, and existing personal health conditions. It also features designated fields for supporting documentation and client authorization.
Built to streamline client onboarding, this template eliminates back-and-forth emails and ensures advisors have accurate, structured data ready for risk evaluation from day one.
Key features
- Capture complete client medical, occupational, and lifestyle risk data in one submission
- Include fields for nicotine status, alcohol use, and hazardous pastimes
- Collect details on family and personal medical histories effortlessly
- Provide links or descriptions for supporting documents and verification
- Easily customize sections to match specific insurance carrier underwriting guidelines
Use cases
- Life and income protection insurance pre-underwriting evaluations
- Financial advisory client onboarding and fact-finding sessions
- Risk profiling for specialized disability and health insurance policies
What this form collects
- Adviser Name (Short answer)Enter the name of the financial advisor or broker managing this file.
- Adviser Code (Short answer)Provide your internal adviser or agency reference code.
- Client Full Name (Short answer)Enter your first, middle, and last name.
- Client Age (Short answer)Enter your current age in years.
- Client Gender (Dropdown)Select your gender for underwriting classification purposes.
- Best Contact Number (Short answer)Enter a phone number where we can reach you during business hours.
- Benefits Being Assessed (Checkboxes)Select all insurance coverage types you are applying for.
- Height and Weight (Short answer)Provide your approximate height and weight (e.g., 5'10", 175 lbs or 178 cm, 80 kg).
- Nicotine Use Status (Last 12 Months) (Multiple choice)Have you used cigarettes, cigars, e-cigarettes, vaping devices, or nicotine replacement products in the past 12 months?
- Alcohol Use Status (Short answer)Describe your typical alcohol consumption (frequency and approximate standard drinks per week).
- Occupation Details (Paragraph)Describe your current job title, primary duties, and whether your role involves manual labor, travel, or height work.
- Hazardous Activities and Sports (Multiple choice)Do you participate in any hazardous pastimes such as aviation, scuba diving, rock climbing, motor sports, or skydiving?
- Occupation Change Status (Last 12 Months) (Multiple choice)Have you changed your occupation or employer within the past 12 months?
- Personal Medical Conditions Details (Paragraph)List any past or current medical conditions, surgeries, injuries, or ongoing treatments. Include dates and treating physicians if known.
- Non-Disclosed Drug or Medication Use (Last 5 Years) (Multiple choice)Have you taken any prescription medications or recreational drugs regularly over the past 5 years?
- Family Medical History (Paragraph)Have any immediate family members (parents or siblings) suffered from heart disease, stroke, cancer, diabetes, or inherited disorders before age 60?
- Australian Residency / Citizenship Status (Dropdown)Select your current residency or citizenship status.
- Overseas Trip Booked Status (Last / Next 12 Months) (Multiple choice)Do you have any upcoming overseas travel planned in the next 12 months, or have you traveled to high-risk regions recently?
- Supporting Documents Upload (Paragraph)Please paste a link to your file (Google Drive, Dropbox, etc.) or describe the medical reports, ID, or financial documents you wish to attach.
- Additional Notes (Paragraph)Share any additional information or context that may assist with your underwriting pre-assessment.
- Client Authorisation Status (Multiple choice)Do you declare that the information provided is true and correct to the best of your knowledge and consent to us submitting this pre-assessment to underwriters?
- Form Rating (Linear scale)How would you rate your experience completing this pre-assessment form?
FAQ
What is an insurance pre-assessment form used for?
It is used by financial advisors and underwriters to collect preliminary health, lifestyle, and occupational information from a client before submitting a formal insurance application.
Can I customize the medical and lifestyle questions?
Yes. Once you convert this template to Google Forms, you can add, remove, or modify any question to suit your specific underwriting criteria or insurance products.
How do clients attach supporting documents?
The form includes dedicated fields where clients can paste links to cloud-stored files or describe documents they wish to provide to their advisor.
Is this template free to use?
Yes, this template is completely free to convert and use via Google Forms.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.