REQUEST AN INSURANCE QUOTE

Personal Details (all quotes)

Name:*

First Last

Residential Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Best Contact Phone Number*

Email Address*

Gender*

Male
Female

Date of Birth

Age at your next Birthday*

Please select the protection you want

Income Protection Insurance
Life & TPD Insurance (combined)
Life, TPD & Trauma Insurance (combined)
Life Insurance only
TPD Insurance only (stand-alone)
Trauma Insurance only (stand-alone)

*TPD = Total & permanent Disability

Amount Requested (Income Protection Insurance)

Amount Requested (Life, TPD & Trauma Insurance - combined)

Amount Requested (TPD Insurance)

Amount Requested (Life & TPD Insurance - combined)

Amount Requested (Life Insurance only)

Amount Requested (Trauma Insurance only)

Please provide the following (all quotes)

Occupation

Job Title

Professional or trade qualification

Industry

Work Status

Permanent Full Time (min. 30 hrs/ week; 5 days/ week)
Permanent Part Time
Casual
Contractor
Home Duties

Smoking Status

Smoker
Non Smoker

(non-smoker means not smoking anything in the last 12 months)

Your Height (cms)

Your Weight (kgs)

Most serious medical issue to date

For income Protection

Are you:

Employed
A Sole Trader
Employee of own company / trust
In a partnership

Annual Gross Salary ($)

(Employed only)

Includes Super?

Yes
No

OR Annual Business Income ($)

(i.e. Revenue – Expenses; before tax)

Hours per week worked

Weeks per year worked

Type of work

(answer in percentage, the total should be 100%)

Inside office or similar

Onsite

Driving

Manual

Waiting period*

30 days
60 days
90 days
1 Year
2 Years

* Waiting period is how long you are unable to work before you qualify for a monthly benefit. It depends how long you can go without income. Please keep in mind that income protection policies usually pay 30 days in arrears after you have served the elected waiting period. # Benefit period is how long you will be paid benefits after the event of a claim.

Benefit period*

2 Years
5 Years
to age 65

Important – Please Read

All quotes will be provided at ‘standard rates’. This is the lowest premium price you will pay subject to an insurer’s underwriting process. The underwriting process assesses additional risk to the insurer due to your past and present health issues, pre-existing conditions, family history, additional occupation risk (e.g. working at height), and dangerous pastimes (e.g. scuba diving, motor sports).

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