Occupational Questionnaire
To assist us in the assessment of your claim, please complete the questionnaire below. The questionnaire will provide insight
your education, skills, training and work experience.
Please note the form is to be completed by the individual who is claiming the benefit.
1. PERSONAL DETAILS
Claim number
Full name
Street address
Suburb State Postcode
DD / MM / YYYY
Date of birth
Contact number
2. OCCUPATION DETAILS
1. Occupational details (prior to incapacity)
Occupation and
job title
Name of employer
Nature of business
(Industry type)
DD / MM / YYYY
Date of commencement of employment
How many years were you employed with this employer?
2. How many hours per day and days per week did you work prior to the onset of your condition?
Please also stipulate if you worked night shift, on call, or regular overtime.
3. Please tick the box that best describes the job you were doing prior to ceasing work.
Lifting up to 4.5kg, brief walking and standing, sitting most of the day
Lifting up to 9kg occasionally and 4.5 kg frequently
Lifting up to 23kg occasionally and 11kg frequently
Lifting up to 45kg occasionally and 23 kg frequently, mostly manual work
TAL Life Limited ABN 70 050 109 450 | AFSL 237848
TALR7885/0817 OCCUPATIONAL QUESTIONNAIRE | PAGE 1 OF 4
2. OCCUPATION DETAILS (continued)
4. During the course of your normal routine, what percentage of time does the job involve the following activities?
Please tick appropriate boxes.
NEVER 1-5% 26-50% 51-75% 76-100%
Walking
Walking on
uneven ground
Driving
Reaching above
shoulder height
Reaching at
shoulder height
Reaching below
shoulder height
Bending or crouching
Kneeling or crawling
Sitting
Standing
5. Describe the nature of your normal work activities and percentage of time spent on each activity.
Customer Service No Yes %
Admin / Clerical No Yes %
Supervisory and
managerial No Yes % and stipulate the number of staff
Light manual No Yes %
Heavy manual No Yes %
6. Please provide a breakdown / list of your work duties during an average working day in your previous role.
7. What tools or equipment do you usually need to do your work? Eg computer, power tools, bulldozer.
8. Please provide details of your education including the year you completed your education and the levels achieved.
9. Do you have any University, TAFE or College of Advanced Education qualifications?
No Yes Please specify the dates in which you completed the qualification.
OCCUPATIONAL QUESTIONNAIRE | PAGE 2 OF 4
2. OCCUPATION DETAILS (continued)
10. Please list your current or expired licences, tickets including any professional memberships.
11. Please indicate your level of proficiency with the following:
Eg nil, basic, intermediate and advanced.
Email
Internet
MS Word
MS Excel
Any other computer applications?
No Yes Please stipulate.
12. Please provide details with regards to licences below.
Do you have a current Driver’s Licence? Yes No
Any other licences?
No Yes Please stipulate.
13. Please provide details of the jobs you have done or undertaken since leaving high school.
JOB EMPLOYER APPROXIMATE DATES DUTIES
14. What recreational activities, past times or hobbies do you participate in? Please indicate if you are no longer able to
participate in these.
OCCUPATIONAL QUESTIONNAIRE | PAGE 3 OF 4
3. PRIVACY
Please note that the information provided in this form will be collected, managed, secured and disclosed in accordance with
our Privacy Policy which is available on our website at www.tal.com.au or free of charge on request.
Name
Signature
✗ Date
DD / MM / YYYY
SUBMITTING THIS FORM
TAL Life Limited claims@tal.com.au (02) 9465 2181 If you have any questions,
GPO Box 5380 please contact us on
Sydney NSW 2001 1800 101 016.
OCCUPATIONAL QUESTIONNAIRE | PAGE 4 OF 4
