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Please fill in the following information to request a quote:
General Information
First Name
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Surname
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State of Residence
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Post Code
Daytime Telephone
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Best Time to Call
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Gender
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Choose Gender
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Date of Birth
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(dd/mm/yyyy)
Height in cm
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Weight in kg
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Please enter an amount for at least one of the types of cover listed below.
How much Term Life cover do you require?
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How much should you have?
Do you want to include a Lump Sum payable following Total & Permanent Disability.
*
How much should you have?
Do you want to include a Lump sum payable on diagnosis of specified major medical conditions (trauma cover).
*
How much should you have?
Do you want to include Income Protection cover? (Monthly benefit payable in the event of disablement))
*
Most insurance companies limit the amount of Income Protection cover to a maximum of 75% of your taxable income.
Do you want to include business expense cover?
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What expenses can I cover?
Are you self employed?
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How quickly do you want to be on claim
14 days
30 days
60 days
90 days
120 days
240 days
How long do you want to be paid a benefit
2 years
5 years
to age 65
What is your occupation?
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In what Industry do you work?
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Medical History
Are you a smoker?
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Yes
No
Do you take any prescription medications? If yes, please state the name of medications?
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Are you self employed?
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Other information or comments
Important: Please do NOT proceed to the next page if this is not a genuine enquiry. By proceeding you are confirming that the information you have provided is accurate and that you wish to receive comparative quotes and options .
Please fill out and submit a separate form for your spouse / partner
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