Life Broker Services 
Gisborne Ltd 
Securing Your Future 

Please Complete this Quote and Email, Mail or Fax to the address below:

INCOME PROTECTION

Please complete a) or b)			a) EMPLOYEE	b) SELF-EMPLOYED
1.	Gross Income p.a.			$			$
2.	Gross Business Expenses p.a.		$			$
3.	Unearned income -eg. rent/Dividends	$			$
4.	Monthly Benefit required		$			$
5.	Wait (Excess) period required	4 wk, 8 wk, 13, 26, 52	4 wk, 8 wk, 13, 26, 52
6.	Benefit Term			2 yr, 5 yr, to 60, 65, Life	2 yr, 5 yr, to 60, 65, Life
7.	Other Benefit Options - Booster
			            - Hospitalisation

BUSINESS EXPENSES

Gross Income Generated by the Business		$
Less Cost of Goods Sold				$
Less Cost of Capital Items				$

Total Business Expenses				$

What % of the total business Income is generated by you?		%
What % of the total business income is generated by other 
income producing staff?						%
What % of the total business Expenses are you responsible for?	%
What is the monthly cost for a Locum to replace you?		$


What existing policies do you have?

INCOME PROTECTION?	Click on the boxes to take you to the next questions
Company
Monthly Benefit		$
Wait Period
Benefit term
Type of Policy			Indemnity/Agreed value/Loss of earnings
Monthly Premium		$

What existing policies do you have?
LIFE COVER
Company
Sum Insured
Type of insurance		Term/WOL/Endowment
Type of Cover			Level/Indexed
Cash Value			$
Monthly Premium		$

What existing policies do you have?
TRAUMA/CRITICAL CARE
Company
Sum insured			$
Essential or Deluxe Policy
Stand Alone or Accelerated
Monthly Premium		$

What existing policies do you have?
TPD
Company
Sum Insured			$
Essential or Deluxe Policy
Own occupation or any Occupation
Monthly Premium		$

What existing policies do you have?
SUPERANNUATION
Company
Monthly Contribution		$
Cash Value			$
Locked-in/Non Locked-in
Policy Maturity Date




What existing policies do you have?
SAVINGS/INVESTMENTS
Company
Lumpsum Deposit		$	
Regular Contribution Amount	$
Policy Maturity Date

What existing policies do you have?
SAVINGS/INVESTMENTS
Company
Lumpsum Deposit		$
Regular Contribution Amount	$
Cash Value			$
Reason for Investment
Availability of Funds	- Term of Investment
			- On Call

What existing policies do you have?
MEDICAL INSURANCE
Company
Product Name
Hospital only Cover		Y/N
Excess 				Amount  Nil or $ ____
Premium Payback		Y/N
Full Reimbursement Policy 	80%/100%
Monthly Premium		$

Life Broker Services 
Gisborne Ltd 
Securing Your Future 

PO Box 238 
Gisborne 3801 
New Zealand 
Telephone +64-6-8688126 
Fax +64-6-8687524 
Email info@life-brokers.co.nz

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. 

Please note that this application is not an offer of insurance, but is to be used for the purpose of obtaining Insurance quotations on your behalf.

PRIVACY ACT 
Pursuant to the PRIVACY ACT 1993 the following is brought to your attention:- 
1. This Application collects personal information about you; 
2. The information is collected to evaluate the insurance you seek; 
3. The intended recipient of the information is Life Broker Services Gisborne Ltd, P O Box 382, Gisborne; 
4. The information is being collected and held by Life Broker Services Gisborne Ltd, P O Box 382, Gisborne; 
5. The collection of this information is required pursuant to the common law duty to disclose all material facts relevant to the insurance sought and is mandatory; 
6. The failure to provide this information may result in your application being declined, or your insurance being void from the beginning; 
7. You have rights of access to, and correction of, this information subject to the provisions of the Privacy Act 1993.