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Applicant

Entity Type:

Sole TraderPartnershipCompany (Pty Ltd)Trust

Personal Reference - Reference Name, Relationship, Phone No and Suburb

Upload Documents

Driver’s License – Photo ID & Front and Back

Medicare – Front and Back

Any Additional Supporting Documents

Applicant

Entity Type:

Sole TraderPartnershipCompany (Pty Ltd)Trust

Personal Reference - Reference Name, Relationship, Phone No and Suburb

Upload Documents

Driver’s License – Photo ID & Front and Back

Medicare – Front and Back

Any Additional Supporting Documents

Applicant

Entity Type:

Sole TraderPartnershipCompany (Pty Ltd)Trust

Personal Reference - Reference Name, Relationship, Phone No and Suburb

Upload Documents

Driver’s License – Photo ID & Front and Back

Medicare – Front and Back

Any Additional Supporting Documents

Applicant

Entity Type:

Sole TraderPartnershipCompany (Pty Ltd)Trust

Personal Reference - Reference Name, Relationship, Phone No and Suburb

Questions For All Applicants

1. Are you politically exposed?

YesNo

2. Have you even declared bankruptcy?

YesNo

3. Are you an Australian Citizen/Permanent Resident?

YesNo

Upload Documents

Driver’s License – Photo ID & Front and Back

Medicare – Front and Back

Any Additional Supporting Documents

Applicant

Residential Address (if less than 3 year's provide previous addresses) *

Reason Of Purchase

Upload Documents

Driver’s License – Photo ID & Front and Back

Medicare – Front and Back

Any Additional Supporting Documents

Applicant

Entity Type:

Sole TraderPartnershipCompany (Pty Ltd)Trust

Personal Reference - Reference Name, Relationship, Phone No and Suburb

Upload Documents

Driver’s License – Photo ID & Front and Back

Medicare – Front and Back

Any Additional Supporting Documents

Applicant

Residential Address (if less than 3 year's provide previous addresses) *

Residential Status

OwnerMortgageRentingBoardingRelatives

Provide Further Description

• Owner – Unencumbered

• Mortgage – Name of Lender, Initial borrowed amount, Amount owing, Monthly Repayments.

• Renting – Name of Agent, Address of Agent, Contact Name & Phone Number of Agent, Weekly/Fortnightly/Monthly Rent repayments.

• Boarding – Considered as Private Rent, Provide Contact Name & Phone Number of Landlord, Weekly/Fortnightly/Monthly Rent repayments.

• Relatives – If living with family or friends and no rent is paid

Employer Details - Business Name, Contact Name & Phone No (If less than 3 year's provide previous addresses.)

Income

Salary/Wages - Take Home Pay $

WeeklyFortnightlyMonthly

Other Income (specify)

WeeklyFortnightlyMonthly

Government/tax-free income sources (specify)

WeeklyFortnightlyMonthly

Total Monthly Income

Assets

Residential Home - Value of property - Address

Liabilities

Other Loans – Zippay, Afterpay etc. Name of Lender, Initial borrowed amount, Amount owing, Monthly Repayments.

Expenses

Are you and your family adequately protected?

If your income were to stop, would you be able to continue your current lifestyle, including mortgage, car loan, children’s education, holiday etc?

YesNoUnsure

If yes, how long would you be able to continue your current lifestyle if your income did stop?

<1 mth2 mths3 mths6 mths1 year5 yearsIndefinitely

Would your current insurances be enough to pay off your debts and keep your family comfortable for the rest of their lives in the event of your untimely death or incapacitation?

YesNoUnsure

Wealth/debt protection acknowledgement

I/we confirm that (tick relevant box)

I/we DO want to discuss my/our debt protection needs

YesNo

I/we do NOT want to discuss my/our debt protection needs

YesNo

I acknowledge that:

I/we have not been provided with a personal recommendation by our broker/consultant to acquire or not acquire debt protection or life insurance products; andMy/our broker/consultant has recommended that I/we consider consulting a specialist to discuss my/our full risk insurance needs.

Upload Documents

Driver’s License – Photo ID & Front and Back

Medicare – Front and Back

Any Additional Supporting Documents

3 x Payslips