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Request an Insurance Quote

Request an Insurance Quote

Would you like an insurance quote? Please complete the form below and click ‘submit’ and we’ll get back to you as soon as possible.

Personal Details
Title *
First name *
Last name *
Date of birth * / DD / MM YYYY
Email *
What is the best time to contact you? *
If other time, please specify
Preferred phone *
Postcode *
Have you ever been declined insurance in the past? *
If yes, what was the reason why you were knocked back?
Dependants
Do you have any children? *
If yes, how many and what are their ages?
Lump Sum Insurance
How much life insurance cover would you like
Do you want to include Trauma Insurance? *

(a tax free lump sum payable on diagnosis of specific medical conditions such as cancers, heart attacks and so on)?
If, yes, how much trauma insurance would you like a quote for?
Do you wish to include Total and Permanent Disability (TPD) Insurance? *
If yes, how much TPD insurance would you like a quote for?
Income Protection Cover Amount
Do you want to include an income protection quote? *
If yes, what is your annual income?
Choose a waiting period
Choose a benefit payment period
Physical details

In calculating premium rates and your eligibility for a life policy, there are a number of factors that need to be taken into consideration
Height
Weight
Are you a smoker (select smoker if you smoked within the last 12 months)?
What is your occupation?
Are you required to do any physical work?
If yes please specify what physical work you are required to do and how often
Health Details

Not only does your own health influence your eligibility and the price you pay for your insurance, some aspects of your immediate family health history is also taken into account.
Do you take any subscription medications? *
If yes, please specify the name of medication, dosage (if known), the condition being treated and the length of time being taken
Have any of your parents or siblings had cardiovascular decease or cancer
If yes, please explain, including age of onset, diagnosis and death (if applicable)
Have you ever been treated for the following: * Aids Alcohol or drugs Alzheimers disease Asthma Cancer Cholesterol Depression Diabetes Heart disease Hypertension Kidney disease Liver disease Mental illness Pulmonary disease Stroke Ulcers Vascular disease Other None
If other, please specify
If you checked any of the above other than ‘None’, please explain
Occupational details

Another key factor in determining the price you pay for your life insurance and/or income protection is the type of work that you do and your employment status.
What is your employment status?
What is your employment status?
If other, please specify
What is your occupation title?
In what industry do you work?
What qualifications do you hold?
Please explain the nature of your work (your day to day activities)
Other information
Is there anything else you would like to add that was not previously mentioned that you think can affect your insurance premiums or eligibility?
Where did you hear about us? *
If employer or association, please specify name

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