Date of application * First Name * Last Name * Phone * Email * If you currently have health insurance, who is it with? How much do you pay annually? * Occupation * How many hours do you work per week? * What is your annual Income? * How many employers have you had in the last 5 years? * Do you have Kiwisaver? How much? * What are your goals short-term (1-2 years) – e.g. save for a holiday * What are your goals medium-term (2-5 years) – e.g. pay off a car * What are your goals long-term goal (5 years onwards) – e.g. buy a house * Marital Status * Single Married Divorced Widowed Civil Union If you have a spouse, is your spouse working? or looking after children full time/part-time? * Do you have any children? How many? * If you have a spouse and children, are they your dependents? if so, please state their names and DOB * If you’re not a resident of New Zealand: – How long does your visa have left? – When did you arrive in New Zealand? – Are your family here or overseas? * Do you own a house? If you own a house, how much are: – Estimated value of house – The monthly repayments – Current balance of home loan? * Do you own any rentals? If you own a rental, how much is: – Monthly rental income – Estimated value of house – The monthly repayments – Current balance of rental loan? * How much rent p/w or p/f or p/m? Does it include utilities? or not? * Do you have a car? How much was it? If purchased through a car loan, how much do you have left to pay off? * After expenses, how much do you save weekly? * How much savings do you have? * Do you have a will? * Smoker or non-smoker? cigarette and/or vaping? How often do you use your vape in a day/how many cigarettes sticks a day * – Do you have any existing medical conditions? – Any time of hospitalization because of sickness or injury? – Any operations? – Any time you have seen a medical specialist due to sickness or injury? Taken time off work due to a medical condition or injury? * – Has your mother, father, brother/sister been diagnosed with cancer, diabetes, heart attack, stroke, etc.? * Height * Weight * What are your GP’s details? * Do you participate in any sports or outdoor activities e.g. gym, running, fishing * Beneficiary details: – Full Name – DOB – Address – Email – Mobile Number * Would you like to pay fortnightly or monthly? * Fortnightly Monthly Account Details Website Submit
