By requesting a no obligation, free quotation from Lifequotes, you will see how to save up to 40% on your life insurance premiums.   If you have not already done so click here to visit our requirements calculator.
Simply complete this form and send.

Any information we collect remains confidential and privileged and will only be used to obtain a quotation for you. For a full copy of our privacy statement, click here.

Full Name:

Street:       

Suburb:       

State:        

Postcode:  

AUSTRALIA
Day Phone: 

Night Phone:  

Fax:          

Email:        

Our service standard is to forward you your quotation by email within 24 hours or the next working day. In addition we will post to your mailing address the hard copy of the quotation along with the Product Disclosure Statement and application forms should you wish to apply for the insurance cover.

This information will remain confidential at all times and will not be given to any third partyl.

GENERAL INFORMATION

Male  Female    

Do You Smoke:
Yes  No

Occupation:            


Date Of Birth:         

Professional Qualifications:

Where did you hear about us?
Please choose oneAustralian Financial ReviewPersonal Investment MagazineThe AgeThe Sydney Morning HeraldNewspaper/Magazine ArticleLink From Other SiteWeb SearchOther

TERM LIFE:
Death Cover Amount:                    

Include Total And Permanent Disablement Cover?
Yes    No

TRAUMA COVER:
Trauma Cover Amount:

Include Total And Permanent Disablement Cover?
Yes   No

INCOME PROTECTION:

Monthly Benefit Required:

Waiting Period (Days):   
14 30 60 90 180
Benefit Payment Period:
2 years   5 years 
To Age 65 To Age 70 
Lifetime

BUSINESS EXPENSES COVER
Monthly Benefit Required:

Waiting Period: 
14 Days     30 Days