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Basic Details
First Name
*
Last Name
*
Age
*
Gender (at birth)
*
Please Select
Female
Male
Do you smoke?
*
Please Select
Yes
No
Who are you looking to insure?
*
Please Select
Just me
Me and my partner
Our family
My kids
Other
Insurance Details
Next, tell us a about what you're looking for, and what cover you have already (if any)
Which types of insurance are you interested in?
*
Life Cover
Trauma Cover
Income Protection
Disability Cover
Health Insurance
Unsure
Business Insurance
Group Cover
Do you currently have any insurance?
Please Select
Yes
No
Yes - through my workplace
If so, who is your current insurance policy with?
Do you have pre-existing conditions?
Please Select
Yes
No
Unsure
If so, mention them here if you are happy to...
Personal Circumstances
These questions are optional, but they will give us further insight into your personal circumstances
What is your annual income?
How many people depend on you?
Do you have a mortgage?
Please Select
Yes
No
Are you interested in discounts based on maintaining a healthy lifestyle?
Some providers offer discounts up to 20% to reward you for looking after yourself
Yes
No
I want more information
Contact Details
Finally, let us know how we can get in touch with you
Email address
*
Phone number
*
Your privacy is important to us, and we value your trust. To understand how we collect and use your information, you can view our privacy policy
here
.
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