First Name *

Last Name *

Email *

Broker

Phone Number *

What is your date of birth? *

Where are you based? (city or town)

What is your approximate height? *

What is your approximate weight?

What is your sex? *

Male

Female

What is your Residency status in New Zealand? *

NZ Citizen

NZ Resident

NZ Permanent Resident

NZ Work Visa - 1 year remaining

NZ Work Visa - 2 or more years remaining

Australian Citizen

Non Resident in NZ

Getting a work visa

What is your occupation? (your job title or what you do for a job - please describe your duties) *

What is the status of your employment? *

Employed Full-time

Employed Part-time

Self employed full-time

Self employed part-time

Employed by own company full-time

Employed by own company part-time

Do you smoke or vape? *

No, I don't smoke or vape

Yes, I smoke (cigarettes or cigars)

Yes, I vape (nicotine based vaping products)

Yes, I vape (fruit based vaping products only)

Do you have any pre-existing conditions? (Common pre-existing conditions are: back problems, injuries, ADHD, diabetes, high blood pressure, and high cholesterol. Include any injuries, operations, surgeries or medical treatment you have had in the past.)

Yes

No

Please list your pre-existing conditions below.

Are you currently taking any medication on a regular basis?

Yes

No

Please list your medication below

Would you like to add your partner to this application? *

No, I just want health insurance for myself

Yes, I'd like health insurance for my partner, as well

Your partner's contact info

Partner First name

Partner Last name

Partner Phone number

Partner Email

What is your partner's date of birth?

What is your partner's approximate height?

What is your partner's approximate weight?

What is your partner's sex?

Male

Female

What is your partner's Residency status in New Zealand? Type of visa they hold

NZ Citizen

NZ Resident

NZ Permanent Resident

NZ Work Visa - 1 year remaining

NZ Work Visa - 2 or more years remaining

Australian Citizen

Non-Resident in NZ

Geeting a work visa

What is your partner's occupation? Their job title or what they do for a job - please describe their duties

What is the status of your partner's employment?

Employed Full-time

Employed Part-time

Self employed full-time

Self employed part-time

Employed by own company full-time

Employed by own company part-time

Does your partner smoke or vape?

No, they don’t smoke or vape

Yes, they smoke (cigarettes or cigars)

Yes, they vape (nicotine based vaping products)

Yes, they vape (fruit based vaping products only)

Does your partner have any pre-existing conditions? Common pre-existing conditions are: back problems, injuries, ADHD, diabetes, high blood pressure, and high cholesterol. Include any injuries, operations, surgeries or medical treatment you have had in the past. *

Yes

No

Please list your partner's pre-existing conditions below

Is your partner currently taking any medication on a regular basis? *

Yes

No

Please list your partner's medication here

What type of insurance are you interested in? Choose as many as you like.

Personal Risk Insurance (life, trauma, health, income, mortgage or rent)

Business Risk Insurance (key person, business expenses)

Commercial Insurance (professional indemnity, public liability)

General Insurance (vehicle, house, contents)

I'm unsure

As licensed Financial Advisors, we're able to advise you on which policies may suit you. This advice is free and available at no charge to you. We receive commission from the insurance providers we work with, as outlined in our Disclosure Statement. With that in mind, please choose from the following options:

I don't need advice – I already know the amount and type of insurance I need and just want a quote

I need advice – I'm not sure the type or amount of insurance I need and would like advice

So let's get into it. These questions help us to assess your unique situation to ensure you're getting the right insurance for your needs.

What are your goals and priorities for this year? What you would like to achieve or do within the next 12 months – be creative! Choose as many as you like.

Take a holiday

Grow savings

Start a family

Pay down debt/mortgage

Purchase a house

Get married

Other

Do you have any dependents/children? Dependents are those who rely on you for financial support.

No

Yes, I have one child

Yes, I have two children

Yes, I have three or more children

Would you like to get cover for your dependents or children?

Yes

No

What is your monthly rent or mortgage payment?

Approximately how much total savings do you have? Include the balances of savings accounts, term deposits, investments, Kiwisaver etc. If applying with a partner, include both partner's savings.

Approximately how much total debt do you have? Include balance of mortgage, car loans, personal loans, credit cards, overdrafts etc. If applying with a partner, include both partner's debts.

Do you rent or own the house you live in?

Rent

Own

How many years do you have remaining on your mortgage? Please enter the length of time until your home loan is paid off.

What is your base annual salary or wages (before tax)? The amount of money you earn on a yearly basis excluding bonuses or overtime. If applying with a partner, include both of your salaries on a separate line.

Does your employer offer group health or life insurance?* Example; Southern Cross, Nib or MAS etc

Yes

No

I am not sure

How much cover would you like? This is for estimate purposes - example; $500,000 Life cover and $250,000 Trauma cover

Which of the following insurance policies do you currently have in place? *

I don't currently have any insurance policies in place

Life Insurance (e.g. trauma, income/mortgage protection)

Health Insurance (e.g. personal or group/work scheme)

General insurance (e.g. vehicle, house, contents)

Business insurance (e.g. key person, business expenses)

Commercial insurance (e.g. professional indemnity, building)

I'm not sure

Nice one! Your buffer is taking shape. Before we go, is there anything else you'd like to add or ask about?

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