Life Broker Services Gisborne Ltd Securing Your Future Please Complete this Quote and Email, Mail or Fax to the address below: MEDICAL INSURANCE d. MEDICAL INSURANCE List those you require quotes for: Person 1 NAME Date Of Birth Occupation: Telephone: Fax: E-Mail Address: Smoker: Y N Person 2 NAME Date Of Birth Occupation: Person 3 NAME Date Of Birth Occupation: 1. Are you interested in health insurance: Yes, I am definitely interested No I already have health insurance but would be interested in other options. 2. Which component of health insurance is most important to you: Day to day costs such as doctor's bills, prescriptions, specialists, physio etc. Cost of all operations and access to immediate hospital treatment. Both of the above. 3. Non-surgical hospitalisation treatment is increasing e.g. cancers, respiratory disorders, strokes, angina etc. Which level of cover do you prefer: Surgical & Non-surgical (Base Component). Surgical, Non-surgical, Non-Hospitalised Specialists & Tests. Surgical, Non-surgical, Non-Hospitalisation Specialists & Tests, GP's costs & Prescriptions. All of the above plus Dental & Optical. 4. Please rate 1-7 in order of preference (were 1 is least and 7 is most important) X if not important to you: GP's and Perscriptions Benefit Premium Payback Paid Family Cargiver Paid Support Person Death by Medical Misadventure (Life Cover) Specialists & Tests (Out of Hospital) Excess for claims (Select an Amount) 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; You have rights of access to, and correction of, this information subject to the provisions of the Privacy Act 1993.