KSL

FREE ASSESSMENT OF YOUR INSURANCE PORTFOLIO

Please complete the form below:


Name:
Phone:
Email:
Date of birth, or age next birthday:
*Occupation:
**Income ($)
Marital status:
Spouse's name:
Spouse's date of birth or age next birthday:
*Spouse's occupation:
**Spouse's income ($)
I am supporting children:
Number of children:
Children's ages:
Children's genders:
I have a mortgage:
Amount of mortgage $:
***Other debt:
***Amount of other debt $:
Total debt (including mortgage) $:
I am a smoker:
Any medical problems?
Type of medical problems:
Any hazardous activities?
Type of hazardous activities:

* Occupation is required so we can determine your occupation rating for income protection. Spouse occupation details are required for dependency considerations.

** Please provide gross personal income. This is required so we can provide recommended sums insured and calculate 75% of salary income replacement sum insured.

*** N.B. Other debt includes student loans, credit cards and personal guarantees.

My existing insurance is as follows:
Life insurance (amount $):
Monthly Premium ($):
Insurance Company:
Crisis/Critical Illness/Trauma insurance ($):
Monthly Premium ($):
Insurance Company:
Total & Permanent Disablement Insurance ($):
Monthly Premium ($):
Insurance Company:
Income Protection Insurance (per mth):
Monthly Benefit ($):
Monthly Premium ($):
Insurance Company:
Benefit payable for: or to age
waiting period
Type of Contract:
Medical Insurance
Doctors' Bills:
Specialists & Tests:
In Hospital:
Surgery Only:
Monthly Premium ($):
Insurance Company: