New Insurance Application

PERSONAL DETAILS OF APPLICANT 1

OPPORTUNITY TYPE *

Title *

Full Name *

Gender *

Email Address *

Phone *

Date of Birth (dd/mm/yy) *

Country/Place of Birth *

Marital Status *

Employment Status *

Occupation *

Employer Name *

Time at Employer *

PERSONAL DETAILS OF APPLICANT 2

Title *

Full Name *

Gender *

Email Address *

Phone *

Date of Birth (dd/mm/yy) *

Country/Place of Birth *

Marital Status *

Employment Status *

Occupation *

Employer Name *

Time at Employer *

DEPENDANT INFORMATION

Name, Gender & Date of Birth of Dependants (Enter Information or N/A if Not Applicable)

PROPERTY

Do you own a property?

Property Address:

Estimated Property Value:

How is this property currently used?

Who owns this property?Applicant 1Applicant 2Not applicable

WILLS

Do the Applicants have a will/wills?

Applicant 1 *

Applicant 2 *

Do you currently have an enduring power of attorney?

Applicant 1 *

OTHER ASSETS AND INVESTMENTS

KiwiSavers

Name of KiwiSaver provider (Applicant 1)

Balance

Other Assets

Name of KiwiSaver provider (Applicant 2)

Balance

Other Assets

MEDICAL QUESTIONNAIRE FOR APPLICANT 1

Height (cm) *

Weight (kg) *

Has Applicant had any conditions since birth? *

Has Applicant had any hospital or surgical procedure? *

Has Applicant taken any medication for more than one week? *

Is Applicant experiencing, has ever experienced or had symptoms of the following? *

If yes, please describe this issue *

Have any of Applicant's first-degree relatives (parents or siblings) ever experienced or had symptoms of the following conditions? *

which family member is/has been affected by the condition?

MEDICAL QUESTIONNAIRE FOR APPLICANT 2

Height (cm) *

Weight (kg) *

Has Applicant had any conditions since birth? *

Has Applicant had any hospital or surgical procedure? *

Has Applicant taken any medication for more than one week? *

Is Applicant experiencing, has ever experienced or had symptoms of the following? *

If yes, please describe this issue *

Have any of Applicant's first-degree relatives (parents or siblings) ever experienced or had symptoms of the following conditions? *

which family member is/has been affected by the condition?

MEDICAL QUESTIONNAIRE FOR DEPENDANTS

Height (cm)

Weight (kg)

Has Dependant had any conditions since birth?

Has Dependent had any hospital or surgical procedure?

Is Dependant experiencing, has ever experienced or had symptoms of the following?

If yes, please describe this issue

Have any of Dependent's first-degree relatives (parents or siblings) ever experienced or had symptoms of the following conditions?

which family member is/has been affected by the condition?

HOUSEHOLDS

Household Address

Housing Status *

Who lives in this household?

Salary/Wages of Applicant 1

Income Type *

Income (in NZD) *

Period *

Is this amount before or after tax?

Salary/Wages of Applicant 2

Income Type *

Income (in NZD) *

Period *

Is this amount before or after tax? *

EXISTING COVER (Applicant 1)

Policy Provider

Cover Type

Sum Assured (NZD)

Intention

EXISTING COVER (Applicant 2)

Policy Provider

Cover Type

Sum Assured (NZD)

Intention

DEPENDANT(S)

Cover Type

Sum Assured (NZD)

Intention

ADDITIONAL NOTES (Add any relevant details to your application

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New Insurance Application

PERSONAL DETAILS OF APPLICANT 1

PERSONAL DETAILS OF APPLICANT 2

DEPENDANT INFORMATION

PROPERTY

WILLS

Do the Applicants have a will/wills?

Do you currently have an enduring power of attorney?

OTHER ASSETS AND INVESTMENTS

KiwiSavers

MEDICAL QUESTIONNAIRE FOR APPLICANT 1

MEDICAL QUESTIONNAIRE FOR APPLICANT 2

MEDICAL QUESTIONNAIRE FOR DEPENDANTS

HOUSEHOLDS

Salary/Wages of Applicant 1

Salary/Wages of Applicant 2

EXISTING COVER (Applicant 1)

EXISTING COVER (Applicant 2)

DEPENDANT(S)

Contact Details

QuickLinks

Services

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