CONTACT DETAILS

First Name*

Last Name*

Phone*

Email*

Address

City*

State*

Postcode

PERSONAL DETAILS

Occupation*

Industry

Date of birth*

Gender

Female
Male

Smoker?

Smoker
Non-Smoker
Ex-Smoker

If Ex-Smoker date ceased

Height (cm)

Weight (kg)

*COVER REQUIREMENTS (CHOOSE AT LEAST ONE)

Death only $

Total and Permanent Disablement $

Do you wish to include trauma cover? $

Do you wish to include Income Protection cover? $/month

IF YOU REQUIRE INCOME PROTECTION COVER, PLEASE PROVIDE THE FOLLOWING

**Please also complete waiting period and benefit period if looking for income protection

Your Annual Gross Income $

Your Annual Net Taxable Income $

**What waiting period (for income protection) would you like quotes on?

Waiting period

14 days 1 month 2 months 3 months

waiting period

6 months 12 months 24 months

**What benefit period (for income protection) would you like quotes on?

Benefit period

2 years 5 years age 60 age 65