Personal Accident and Illness Insurance Online Quote Form

Please complete the following information and submit this form to obtain an insurance quotation for personal accident and/or illness. Click on the following if you require trades insurance including public liability.

All information you provide must be correct, true, and accurate as incorrect or misleading information may alter our quote and jeopardise cover if you proceed with a policy.

Please refer to the CGIB Financial Services Guide, Privacy Statement, General Advice Warning and Duty of Disclosure before completing this form.

INSURED'S - Details

Insured name*
BusinessAddress* City/Town* Post Code*
Postal Address City/Town* Post Code
Occupation*

COVER Details

PERSONAL ACCIDENT
Employment
Gender
Average Weekly Income*
Less overtime/bonuses/commission
Fixed business expenses e.g. payment for leasing equipment, employees wages, rent, insurance, payroll tax etc.
Non fixed business expenses
Date of Birth* / /
Height* cm's
Weight* kg's
Personal Illness required
Excluded Period of Claim (waiting time prior to claiming)
Benefit Period (Time on claim)
type of Cover
Do you Smoke?
In current business less than 12months?

If yes, advise details of previous occupation (inc duties, experience, employee or self employed)

PREVIOUS INSURANCE - Details

Does the Person to be insured have an existing insurance policy?*
If "YES", please provide the date your existing policy expirers* / /
Please provide the name of the Insurer*
Have you ever claimed for benefits under any accident or illness policy?

INSURANCE - Details

Is the Person to be insured entitled to claim benefit from Work Cover?
Is the Person to be insured entitled to claim benefits from any other existing or intended injury or illness insurance policy?
Has any policy or application for injury or illness insurance concerning the Person to be insured ever been declined, modified,accepted at an increased premium, cancelled or refused renewal?
Has the Person to be insured ever claimed benefits from Work Cover?
Has the Person to be insured ever claimed benefits under injury or illness insurance policy?

If yes to any of the above, please provide details

MEDICAL - Details

Has the Person to be insured in the last 10 years received treatment or advice from a Registered Medical Practitioner (including but not limited to a doctor, chiropractor, physiotherapist or naturopath) in relation to:
Heart, arteries, high cholesterol or high blood pressure or disorders of the circulatory system?
Lungs, asthma, tuberculosis or disorders of the respiratory system?
Kidney, bladder, liver, spleen, bowel or disorders of the genito-urinary system?
Brain, Epilepsy or disorder of the central nervous system?
Stomach, esophagus or disorders of the digestive system?
Head, back, neck or spine or any disorder of the musculoskeletal system?
Depression, psychological, psychiatric or personality disorder?
Drug or alcohol dependence?
Cancer or Tumour?
Diabetes?
HIV, AIDS or AIDS related conditions?
Any disorder of the Eyes or Ears?
Hepatitis?
Any hernia or associated condition?
Ulcers?
Arthritis or rheumatism?
Physical impairment or deformity?
Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?

If yes to any of the above, please provide details

ACTIVITY Details

Does the Person to be insured participate (or intend to participate) in any hazardous pursuit or activities, including but not limited to motor sports in any form, rock climbing or mountaineering, water skiing, snow skiing, snow boarding, horse riding, canyoning, motor cycling, parachuting, abseiling, kite surfing, mountain biking, scuba diving, football of any code or any other body contact sports?

If yes, please provide details

CONTACT Details

First name*
Surname*
Phone No
Fax No
Email Address*
How did you find us*
If other, please provide details

Comments

Mandatory Fields
Thank you for completing our online form.
We will endevour to contact you with your insurance details soon.
We may need to contact you to obtain additional information to provide you with an insurance quotation.
Completion of this form does not put an insurance policy/cover in place - you will need to contact us to arrange insurance cover.
All information you provide must be correct, true, and accurate as incorrect or misleading information may alter our quote and jeopardise cover if you proceed with a policy.
We recommend that you read the relevant Product Disclosure Statement when considering an insurance policy.