Free Life Insurance Quote
Life one Life two First Name* Last Name* Address* Phone* Daytime Phone Email* Date of Birth* (dd-mon-yy) Do you smoke?* yes no yes no Height*  cms  cms Weight*  kg  kg Occupation* Present Life insurance details:
Do you have Life Insurance at present?	Yes No
If Yes, what company? Policy Name/type
Amount of Cover     Death $ NZD $ NZD Disability $ NZD $ NZD Accidental death $ NZD $ NZD Other please list $ NZD $ NZD Current monthly premium $ NZD $ NZD
Date last premium paid	(dd-mon-yy)
Renewal Date, if applicable	(dd-mon-yy)
Any Health Loading	Yes No
Personal statement These questions must be answered 'yes' or 'no' by each Life to be insured.   Question Life one Life two 1 Have you any intention to engage in aerial travel other than as a fare paying passenger, or in pursuits or pastimes considered hazardous by the average person? e.g. Motor racing, Hang gliding, rock climbing etc yes no yes no 2 Have you ever had any disorder of the heart ,lungs, stomach or bowels, kidney back, nervous system, or high blood pressure, diabetes, cancer, tumor, mental disorder, or any other departure from good health? yes no yes no 3 Has a proposal for life, accident or sickness insurance on your life ever been declined, deferred or withdrawn from any company or accepted with a loading? yes no yes no 4 Have you ever received any attention from a hospital, clinic or specialist, including any blood tests in the last five years yes no yes no 5 During the last 12 months have you smoked tobacco or any other substance in any form? If yes please state substance and quantity per day. yes no yes no 6 Have you ever been tested for or received medical advice consulting or treatment in connection with Aids or an Aids related disorder? yes no yes no
If either of you have answered yes to any of the questions above, please provide details.