First Name *

Phone Number *

Last Name *

Email Address *

Date of Birth *

Occupation *

Gender *

Income *

Male Female

Smoker? *

Duties of Occupation

Yes No

Do you have existing insurance? *

Yes No

If Yes, please provide more details such as benefit amount, insurer and premium

Do you have a medical condition or injury that could affect your insurance or been declined in the past for insurance? *

Yes No

If Yes, please provide more detail

Personal Cover

	Life Insurance

	Total & Permanent Disablement

	Trauma Insurance

	Income Protection
	per month

	Income protection waiting period (how long you are unable to work before the insurance company starts paying)
	14 Days 30 Days 60 Days 90 Days 180 Days 365 Days 720 Days

	Income protection benefit period (the maximum amount of time a policy will pay out for)
	1 Year 2 Years to age 60 to age 65 to age 70

Business Cover

	Key Person (replace lost income, training & recruitment costs)

	Debt Protection

	Buy Sell Agreements/ Shareholder protectiion

	Business Expenses insurance

Mode of Payment

We will come back to you with a range of premiums in the market from the following insurers:

Please add any comments or any options that you would like to add to the above policies

Disclaimer:

The premiums that we come back to you with does not constitute an offer of insurance, nor is it advice for your individual circumstances.
Your specific medical and financial situation can influence premiums and the ability to be insured.