Medical Insurance

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

List those you require quotes for
Person 1 Name:
Date of Birth (dd/mm/yyyy):
Occupation:
Phone:
Mob:
Fax:
Email *:
Smoker:	Yes No
Person 2 Name:
Date of Birth (dd/mm/yyyy):
Occupation:
Person 3 Name:
Date of Birth (dd/mm/yyyy):
Occupation:
I actually already have health insurance but would be interested in other options:	yes
2. Which component of health insurance is most important to you:	Day to day costs such as doctors bills, prescriptions, specialists, physio etc.
	Cost of all operations and access to immediate hospital treatment.
3. Non-surgical hospitalisation treatment is increasing e.g. cancers, respiratory disorders, strokes:	Surgical & Non-surgical (Base Component).
	Surgical, Non-surgical, Non-Hospitalised Specialists & Tests.
	Surgical, Non-surgical, Non-Hospitalisation Specialists & Tests, GPs.
	All of the above plus Dental & Optical.
4. Please rate 1-7 in order of preference (were 1 is least and 7 is most important) X if not important to you...
GP's and Perscriptions Benefit:
Premium Payback:
Paid Family Cargiver:
Paid Support Person:
Death by Medical Misadventure (Life Cover):
Specialists & Tests (Out of Hospital):
Excess for claims (Select an Amount):	Nil
	$250
	$300
	$500
	$600
	$1000
	$1200
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Retype Verification Code Here:

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.