Life Insurance

Life Insurance provides cash, to the policy-owner, upon the death of the person insured.

Please fill in the below form for your Free Life Insurance Quote...

Personal Details
Name (Life 1) *:
ZIP Code:
Date of Birth (dd/mm/yyyy) *:
Occupation *:
Address *:
City *:
State:
Country:
Phone:
Mob:
Fax:
Email *:
Smoker *:	Yes No
Name (Life 2):
Date of Birth (dd/mm/yyyy):
Occupation:
Complete below address details only if different from above...
Address:
City:
State:
ZIP Code:
Country:
Phone:
Mob:
Fax:
Email:
Smoker:	Yes No
a. MORTGAGE PROTECTION PLAN – Life Insurance
1. Loan Ammount ($):
2. Loan Term (Years):
3. Interest Rate (%):
4. Payment Frequency:	Monthly
	Fortnightly
5. Payment Ammount ($) - Interest/Principal:
- Interest Only:
Options:	Trauma
	Total Permanent Disability
	Income Protection
b. LUMP SUM FOR FAMILY SECURITY
1. Amount of Cover:	$100,000
	$150,000
	$200,000
	$250,000
	$300,000
	$350,000
	$400,000
	$450,000
	$500,000
	$550,000
	more than $550,000
2. Do you want this amount to remain:	Remains Level
	CPI Indexed
	Decreasing Cover
3. Do you want your premium back after a set term?:	Y (50%)
	Y (100%)
	N
c. MONTHLY FAMILY PROTECTION BENEFIT
1. Child 1 Full Name:
Date of Birth (dd/mm/yyyy):
2. Required monthly benefit ($1000 min):
3. Term benefit required for (years):
4. Is benefit to remain - Level:	Yes No
5. Benefit is related to:	Life 1
	Life 2
	Joint
1b. Child 2 Full Name:
Date of Birth (dd/mm/yyyy):
2b. Required monthly benefit ($1000 min):
3b. Term benefit required for (years):
4b. Is benefit to remain - Level:	Yes No
5b. Benefit is related to:	Life 1
	Life 2
	Joint
1c. Child 3 Full Name:
Date of Birth:
2c. Required monthly benefit ($1000 min):
3c. Term benefit required for (years):
4c. Is benefit to remain - Level:	Yes No
5c. Benefit is related to:	Life 1
	Life 2
	Joint
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Life Broker Services - Declaration

Please note:

1. This is a request form only for the purpose of obtaining insurance quotations on your behalf.
   
   
2. The quotes provided are based solely on the information you have given using standard insurance rates.
   
   
3. These quotes will be obtained by using 'Risk Researcher' from Plan Tech Consulting Group Pty Ltd who are an independent Research company for all NZ & Australian Life insurance products.
   
   
4. The information gathered will be used solely for the purpose supplied and will not be used for any other purpose.
   
   
5. The information will stored securely at our offices in Gisborne NZ.