Name:     Male     Female

Date of Birth:    Smoker     Non-smoker

Occupation:

                    Manual work %        Work Office  %

Cover Type                            Amount of Cover         Desired Term

Life Insurance:                        $              Years

Trauma Cover:                        $              Years

Income Protection: Your Annual Income: $ (Yearly pre-tax & after Business Expenses)

    Required Income Cover: $ (Yearly)

    Waiting Period (Weeks): 48132652 - Choose one or more

    Benefit Paying Term: 2 years    5 years    To Age 65 - Choose one or more

     Self-Employed  Yes     No  If Self-Employed for more than 3 yrs?   Yes     No

Medical Insurance: Existing Cover?    Yes     No  Plan Name:

    Excess Amount?     Surgical Cover only    GP Costs

    Specialists Costs             Dental?            Optical?

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