Disclosures & Authority
All sections must be read and signed by both the client and adviser where shown
The information on this form is not considered by the adviser. It is required by the product issuer. ASIC RG175.4
General Advice Only
As an Authorised Representative of Consilium Advice Pty Ltd Australian Financial Services Licence No. 424974, I can offer you General Advice only on any of the products below. We are unable to take into account any of your financial or personal information. You will need to decide the level of cover you require. And whether the product is suitable for your objectives, financial situation or needs. If you require any further information before making a decision, please refer to the relevant Product Disclosure Statement (PDS)
Confirmation of income
I hereby affirm that the above information that I/we supplied stating my/our income levels are true & correct to the best of my/our knowledge. I/we understand that if I do not supply the correct income details I/we may be disadvantaged at time of claim & this information has not in fact been taken into account by my adviser.
Client Acceptance Authority
In accepting the purchase of this product, I acknowledge that:
• I have received the relevant Product Disclosure Statement
(PDS) and Financial Services Guide and insurance duty of disclosure.
• Neither the Adviser named below nor any other Adviser of
Consilium Advice Pty Ltd has given me any Personal Advice,
nor made any form of, or implied, recommendation about the
• Neither Consilium Advice Pty Ltd nor any of its Advisers shall
be responsible in any matter for any loss or damage suffered
or arising from the purchase of the product.
• It has been explained to me that the advice given has been
General in nature and that my objectives, financial situation
and/or particular needs have not been considered or taken into
account by the adviser when preparing the purchase and
calculating the cost of the above product. purchase and
calculating the cost of the above product.
• I acknowledge that I have been given sufficient information,
including the PDS, to make my own informed decision about
purchasing the product under general advice only.
• I have answered all the medical, personal and lifestyle
questions honestly and completely on the applicable product
application form as required by the product issuer
• I further confirm that I have thoroughly reviewed and rechecked
the answers recorded on the application form and
these answers are completely correct as I have directed the
adviser. I understand that any failure to fully disclose my
medical history or any other relevant matters is my
responsibility and may void my policy or contract. I take full
responsibility of any non-disclosure on any applicable
• I’m aware that Consilium Advice Pty Ltd & the Adviser receive
brokerage, as disclosed in the applicable prospectus,
information brochure, product disclosure statement or other
brochure, for arranging the product for me
• If I do not continue with the purchased insurance product for
a full 2 yrs. or my policy is voided due to any non- disclosure
& the brokerage received by the adviser is returned to the
product issuer, then if requested, I agree to reimburse the
adviser the amount returned to the product issuer for his/her
I hereby direct the authorised representative of Consilium Advice Pty Ltd named below to arrange the Insurance Policy Above on my behalf and I accept and agree that I have only received General Advice in relation to this product.
Insurance Disclosure Warning
What is your duty of disclosure?
You need to be careful to answer all questions on the application truthfully and ensure that you tell the insurer everything that is relevant to the insurer’s decision whether to insure you and, if so, on what terms. For example, any visits to doctors for treatment in relation to an illness or accident. Even if you believe the issue has been resolved and you have recovered, you must disclose this information, as it may be relevant in the event you make a claim on the policy.
Remember you should also disclose any consultations you have (or will have) with doctors after you have signed an application form for insurance, but before the policy has been issued by the insurer.
What happens if you do not meet your duty of disclosure?
There are circumstances in which the insurer can void the policy, vary the sum insured or vary the contract terms for any non-disclosure or misrepresentation by you prior to the date the policy is issued (this includes the duration of the assessment of your application) This also relates to situations where you may have omitted or misrepresented something by accident. Insurers will have access to your previous Medicare history and if you have failed to disclose something then the insurer may choose to void the policy. It is important to note that insurance policies entered into prior 1 July 2014 are subject to a 3-year non-disclosure period. After 3 years the insurer can only void these contracts as a result of fraudulent non-disclosure. If these policies are replaced the disclosure requirements will recommence. From 1 July 2014 life insurance contracts that pay a death benefit or surrender value continue to be subject to a 3-year non- disclosure period. However, for other insurance policies the insurer can void the policy, vary the sum insured or vary the contract terms for non- disclosure at any time.
Please do not cancel any existing policies if you have experienced any changes to your health, occupation, or pastimes that you have not disclosed to the insurer prior to the acceptance of the policy.
I have read and understood my duty of disclosure and agree to advise the insurer of any other relevant information prior to the issue of insurance.
I fully indemnify the Financial Adviser and the licensee for any information that may be false or inaccurate contained in the insurance forms that I have signed. I agree that I am entirely responsible for the completeness and accuracy of this information and I confirm that I have checked my application to be complete and correct to the best of my knowledge or that a reasonable person would be expected to know.
Financial Adviser Details:
Name - Ryan Elliott
ASIC Rep Number - 1258543
FSG version 3 Dated 11th February 2020
Consilium Advice (AFSL 454 874)