|
|
Person 1
|
Person 2 (optional)
|
|
First name |
|
|
|
Last name |
|
|
|
Date of birth |
|
|
|
Occupation |
|
|
|
Are you a smoker? |
Yes No |
Yes No |
|
Are you self employed? |
Yes No |
Yes No |
|
Do you require income protection? |
Yes No |
Yes No |
|
What is your annual salary (including superannuation)? |
|
|
|
What Life Insurance cover amount would you like? |
|
|
|
What TPD amount cover amount would you like? |
|
|
|
What Trauma cover amount would you like? |
|
|
|
Why do you need the requested cover? |
Protect my family in the event of death or disablement |
Compulsory for work purposes |
|
|
Mortgage Protection -cover monthly repayments |
Protect income |
|
|
Shop Around for better premiums and product |
Other |
|
|
Update Will |
|
