Loan Management Centre - Insurance Enquiry Form Page 1

Please tell us a little about what you would like to do:

How much Life Cover do you need? (In the event of death a lump sum payout)	$
How much Income Protection do you need per month? (Most insurance companies limit the amount of Income Protection cover to a maximum of 75% of your earnings)	$
Do you wish to include Total and Permanent Disability cover? (Lump sum payment for a permanent disability)	$
Do you wish to include Trauma cover? (Lump sum payment on major medical condition)	$
Please tell us a little bit about you:
Employment Details - please select one of the following:
Fulltime Self Employed Contract Casual Part time
What is the minimum hours of work performed per week?
Occupation:
In what Industry do you work?
What is your income?
Do you smoke?	Yes No
If no, have you smoked in the past 12 months?
Gender:	Male Female
Your date of birth:

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