Life Broker Services Gisborne Ltd Securing Your Future Please Complete this Quote and Email, Mail or Fax to the address below: LIFE INSURANCE Life Insurance provides cash, to the policy-owner, upon the death of the person insured. · How much life insurance do I need? The amount of life insurance you need depends on two main elements: 1. How much money do you owe - a. Mortgage b. Other debts 2. What funds will you provide for your dependants a. For financial security b. For education · What type of life insurance options may suit my needs? a. A mortgage protection plan – includes death and optional extras of trauma, TPD and income protection to pay the monthly mortgage cost, if you are sick or disabled from earning an income. Error! Bookmark not defined. b. A lump sum sufficient to generate an income to provide for your dependant's future financial security. Error! Bookmark not defined. c. A monthly family protection benefit for a set number of years to provide for living costs and education for your children. Error! Bookmark not defined. LIFE INSURANCE QUESTIONNAIRES Personal Details Name: (Life 1) Address: City: State: Zip Code: Country: Telephone Number: Fax Number: E-Mail Address: Smoker: Y N Name: (Life 2) Address: (Complete The Rest Only if Different from above) City: State: Zip Code: Country: Telephone Number: Fax Number: E-Mail Address: Smoker: (Please Answer) Y N a. MORTGAGE PROTECTION PLAN – Life Insurance 1. Loan Amount: 2. Loan Term: years 3. Interest Rate: % 4. Payment Frequency: Mth/Ftnght 5. Payment Amount: - Interest / Principal - Interest Only OPTIONS – Tick box if quote to include: Trauma Y N Total Permanent Disability Y N Income Protection Y N Error! Bookmark not defined. b. LUMP SUM FOR FAMILY SECURITY OPTIONS – Tick box for quote required: 1. Amount of Cover: 2. Do you want this amount to remain: - Remains Level Y N - CPI Indexed Y N - Decreasing Cover Y N 3. Do you want your premium back after a set term? Y 50% Y 100% N Error! Bookmark not defined. c. MONTHLY FAMILY PROTECTION BENEFIT Please complete 1. CHILD 1 FULL NAME Date Of Birth 2. Required monthly benefit ($1000 min) 3. Term benefit required for years 4. Is benefit to remain - Level Y N 5. Benefit is related to Life 1 Life 2 Joint 1b. CHILD 2 FULL NAME Date Of Birth 2. Required monthly benefit ($1000 min) 3. Term benefit required for years 4. Is benefit to remain - Level Y N 5. Benefit is related to Life 1 Life 2 Joint 1c. CHILD 3 FULL NAME Date Of Birth 2. Required monthly benefit ($1000 min) 3. Term benefit required for years 4. Is benefit to remain - Level Y N 5. Benefit is related to Life 1 Life 2 Joint Error! Bookmark not defined. 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 +64-6-8687588 Fax +64-6-8687589 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.