Senior Shopper Member - Online Enquiry
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Life Insured 1

Life Insured 2

Full Name:* Full Name:*
Your Date of Birth:* Your Date of Birth:*
Your Gender:* Your Gender:*
Occupation:* Occupation:*
Have you smoked
in the Last 12 Months:*
Have you smoked
in the Last 12 Months:*
Card Number: Card Number:
Contact Telephone:* Contact Telephone:*
Email Address:* Email Address:*


State:*
Are you currently taking any prescribed medication:* Yes No
Your Height:*
Your Weight:*


If you require advice regarding a specific sum insured for Life Insurance, Trauma Cover, or Total and Permanent Disability Cover. Please list the level of cover you require next to the appropriate type below, e.g. $500,000:

Life Insurance:
Trauma Cover:
TPD Cover:


If you require advice regarding income protection please enter your gross income i.e. inclusive of superannuation and any bonuses and before tax:

Personal Taxable Income:


I would like more information on (please tick):

Living Expense Insurance Business Planning General Insurance
Trauma Insurance Children’s Insurance Total and Permanent Disability
Business Expense Cover Key Person Insurance Buy/Sell Cover
Superannuation Wills and Powers of Attorney Financial Planning


Is there a particular insurer you would like us to quote on or do you have any Additional comments or questions?:

Comments:


Best time to call:

Before 9am 9am - 12pm 12pm - 3pm 3pm - 6pm


I have read and understood the limited advice warning below:



Limited Advice Warning

The advice to be provided to you by answering the questions above will be based on a limited set of information. Because of that you should, before acting on the advice, consider the appropriateness of the advice having regard to your relevant personal circumstances. If you require a more comprehensive risk plan then please contact us on (07) 3847 7800.
 
 

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