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QuickCover Life Insurance

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CPT*

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Broker*

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Adviser*

Applicant Details

Are you a New Zealand Citizen or an Australian passport holder permanently living in NZ, or do you have a NZ Residency Visa or a NZ Work Permit for a period of at least 2 years? *

Residency status*

NZ/Australian Citizen

Visa/Work Permit

I do not have a NZ Residency Visa or a NZ Work Permit for a period of at least 2 years

Do you plan to work overseas, or live for more than 6 months overseas in the next 2 years? *

Do you plan to work overseas, or live for more than 6 months overseas in the next 2 years?*

Yes

No

Sorry you can not proceed with this application.

First Name(s)*

Last Name*

Title*

Phone / Mobile*

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Date of birth (dd/mm/yyyy)*

DD slash MM slash YYYY

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Gender*

Have you vaped, smoked tobacco or any other substance in the last 24 months? *

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Has the client smoked tobacco or any other substance in the last 12 months?*

Yes

No

Address*

Street Address Suburb City Postal Code

Email Address*

Enter Email Confirm Email

Would you like to nominate a beneficiary? *

Is there a beneficiary?*

Yes

No

Beneficiary Details

First name(s)*

Last name*

Title*

Gender*

Date of birth (dd/mm/yyyy)*

DD slash MM slash YYYY

Phone / Mobile*

Relationship to applicant*

Other relationship to applicant*

Address*

Street Address Suburb City Postal Code

Email Address*

Enter Email Confirm Email

Payment Details

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Cover ($)*

Get a Quote

Subscription Payment Frequency*

Per week

Per fortnight

Per month

Premium payments will be made by Direct Debit to the underwriter DPL Insurance.

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Rate

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Subscription Price ($)

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Age

Day of the week*

First payment date*

DD slash MM slash YYYY

Bank name*

Account*

Account Name*

Do you have individual authority over this account? *

Do you have individual authority over this account?*

Yes

You have read and agreed to the Conditions of Instruction to Accept Direct Debit *

Agreed to the Conditions of Instruction to Accept Direct Debit*

Yes

Quote Details

Quote confirmation as at	12/12/2024
Product	QuickCover Life Insurance
Cover

Applicant Details

Insured person
Phone number
Email address
Address
Date of birth
Gender
Smoker

Payment Details

Premium amount
Frequency
Day of the week
First payment date

I have read and agree to the
Disclosure and Declaration *

Agree to the Disclosure and Declaration*

Yes

Comments

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Greenwich Life Insurance is a business brand of DPL Insurance Limited, a company of Turners Automotive Group

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