Personal Accident & Illness | Request a Quote Step 1 of 3 33% Business DetailsQuote/Cover Commencement Date(Required) Day Month Year Policyholder / Business Name(Required) Business Activity, Industry or Profession(Required) How many years in business?(Required)Australian Business No. (ABN)(Required) Contact Name(Required) First Last Address(Required) Street Address Address Line 2 City State Post Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Website Business Hours Contact Number(Required)Mobile Contact Number(Required)Current Insurer: Current Broker: Interested Parties/Financier Expiry Date Day Month Year Please provide your estimated Revenue for the coming 12 month period by region, and indicate in which territories you are located.Are you located in Australia/NZ?(Required) Yes No Revenue in Australia/NZ(Required)% NEW ZEALAND% NEW SOUTH WALES% VICTORIA% QUEENSLAND% SOUTH AUSTRALIA% WESTERN AUSTRALIA% NORTHERN TERRITORY% TASMANIA% ACTAre you located in EU/UK?(Required) Yes No Revenue in EU/UK(Required)Are you located in USA?(Required) Yes No Revenue in USA(Required)Are you located in the Rest of the World?(Required) Yes No Revenue in Rest of the World(Required)Has any insurer in respect of any insurance policy held by you, your partners and/or directors ever:(Required)Tick all that apply (a) Refused to renew / cancelled or terminated a policy? (b) Refused a claim or required an increased premium under the policy? (c) Imposed special conditions under the policy? (d) Have you been convicted on any criminal offence or been declared bankrupt? (e) Have you had any claims in the past 5 Years? None of the above If you ticked any of the above, give details below:PropertiesHow many properties?(Required)None: Please select if you do not require cover for a physical property/location1 Situation2 Situations3 Situations Personal Accident & Illness / Income Protection – Weekly Benefit max 80%Name(Required) DOB(Required) Day Month Year Height(Required)In Centimetres - Type numbers only Weight(Required)In Kilograms - Type numbers only Death and Capital Benefit(Required)Weekly Accident Benefit(Required)Weekly Illness Benefit(Required)Gender(Required) Male Female Other Smoker(Required) Yes No Period of benefit:(Required) 52 weeks 104 weeks Waiting period:(Required) 7days 14 days 30 days Detail pre-existing conditions OTHER INSURANCE REQUIREMENTSAre you interested in any other types of business insurance? Aviation Commercial Motor Vehicle Commercial Strata Construction Corporate Travel Cyber Environmental Impairment Liability (Pollution) Farm Fine Arts IT Liability & Multimedia Libel, Slander & Defamation Machinery Breakdown Management Liability Marine Transit Medical Malpractice Personal Accident & Illness Plant & Machinery Prize Indemnity Product Recall/Contamination Professional Indemnity Public Liability Risk Management Advice Tax Audit Trade Credit Voluntary Workers Workers Compensation Are you interested in any other types of personal insurance? Boat/Jetski Caravan/Camper Trailer/Motorhome CTP Greenslip Home & Contents Landlord Leisure Travel Motor Vehicle Pet Residential Strata How did you hear about us? Google Search Social Media Referral Existing Customer Other Referred by: Any other comments Supporting DocumentsDon't forget to include a copy of your current policy schedule , any pictures etc. Drop files here or Select files Accepted file types: png, jpg, pdf, doc, docx, Max. file size: 16 MB. By doing any of the following: (a) Signing and returning a copy of this form; or (b) Providing the information requested and returning the form to us; or (c) Providing us with instructions to place the policy; You acknowledge that the information provided by you in this form is correct.SignatureDate Day Month Year
