|
|
|
|
|
|
|
Applicant 1 |
Applicant 2
|
|
Gender:* |
|
|
|
|
|
|
Tobacco Use:* |
|
|
|
|
|
|
Annual Income:* |
|
|
|
|
|
|
Occupation:* |
|
|
|
|
|
|
Date of Birth:* |
|
|
|
|
|
|
Estimated Life Lump Sum Cover |
|
|
|
Term Life Cover |
|
|
|
|
|
In the event of your premature death what lump sum payment do you require to pay out your existing debts and maintain your families lifestyle. To estimate how much cover you require use this online calculator
|
|
TPD Cover: |
|
|
|
|
|
What lump sum amount do you require if you are unable to perform the duties of your qualified profession to pay for lifestyle and medical costs in the event you become permanently disabled.
|
|
Critical Illness Cover: |
|
|
|
|
|
How much cover do you require if you suffer a serious illness (cancer, stroke, heart attack etc) to cover medical and ongoing expenses while you are ill. |
|
|
|
How much income protection
insurance do you require? |
|
|
|
|
|
Estimate the amount you require to maintain your current lifestyle. This includes living expenses, mortgages and other repayments
|
|
How long would you like to wait
before receiving your first payment? |
|
|
|
|
|
This is known as the "waiting period". This is the time you wait between making your claim and receiving your first payment. The longer the waiting period the lower the premium.
|
|
How long do you want the benefit to
be paid? |
|
|
|
|
|
This is the length of time the benefit will be paid. Generally, the shorter the benefit period the less the premium.
|
|
|
|
|
|
|
Do you take prescription
medications? If yes state name
of medication dosage and condition
it is treating:* |
|
|
|
|
|
|
Has any of your parents had
cardiovascular disease or cancer? If
so state which one: |
|
|
|
|
|
|
Have you ever been treated for any of the following: |
|
|
|
|
|
|
|
Name:* |
|
|
|
|
|
Suburb / Town: |
|
|
|
|
|
State:* |
|
|
|
|
|
Postcode:* |
|
|
|
|
|
Phone:* |
|
|
|
|
|
Mobile: |
|
|
|
|
|
Email:* |
|
|
|
|
|
Preferred Time To Call* |
|
|
|
|
|
Comments: |
|
|
|
|
|
|
|
|
