Name*:
Address:
E-mail*:
Daytime Phone*:
Evening Phone*:
Mobile Phone*:
1st Applicant Name:
1st Applicant Sex*:
 Male   Female
1st Applicant DOB*:
1st Applicant Smoker in last 12 mths?:
 Yes   No
1st Applicant Occupation:
1st Applicant NZ Resident?:
 Yes   No
2nd Applicant Name:
2nd Applicant Sex:
 Male   Female
2nd Applicant DOB:
2nd Applicant Smoker in last 12 mths?:
 Yes   No
2nd Applicant Occupation:
2nd Applicant NZ Resident?:
 Yes   No
Preferred Excess:
 $0  
$250   (recommended)
$500  
$1000
Names & Ages of any children to be included:
Do any of the applicants have health problems?:
 Yes   No
Do you currently have health insurance?:
 Yes   No
Describe your interest level
in this type of insurance:		 Highly motivated - will buy with right         premium/policy
General enquiry - fact finding and
        considering
Low level of interest but would still like
         to know
Any other comments?
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