InsureSmart Registration

Free Quote & Insurance Advice

Please complete as much of this form as you can. Although it may appear long, it will give us the information required to make an initial assessment of your insurance needs.

NOTE: A seperate form must be completed for each applicant. In order for us to combine your applications, please provide your partner/spouses details in the appropriate box.

Enter the details below to register on this site.
NOTE: The fields with an asterix (*) must be filled in.

Name Details
First Name*:
Last Name*:
Company Name:
Web Address: http://
Postal Address/Contact Details
Street:
Suburb:
City:
State/Region:
Postal/Zip Code:
Country:
Email*:
Phone No*:
Please include area code
Fax No:
Please include area code
Mobile No:
Personal Details
Gender: Male Female
Date of Birth: (e.g.1999)
Survey Questions
What type of policies are you looking for?* (tick as many as apply):
Health Life Trauma Income Protection
Mortgage Protection KiwiSaver Golden Life
Partner/Spouse - If these policies will cover a partner or spouse as well, please enter their full name and date of birth(they will also need to complete this form):
Are you a smoker?:*
Yes   No 
Employment Status:*
Not Employed   Employed   Self Employed 
Employment Duration:
Less than 3 years   More than 3 years 
Weekly Hours Worked:
Less than 30 hours   More than 30 hours 
Occupation:
List your dependents, their date of birth and their relationship to you(if none, type 'nil'):
Annual Income (before tax):
Assets - List your existing assets & their approx. value:
Liabilities - List your existing liabilities & the total amount left owing (ie.mortgage, loans, HP, credit cards):
Monthly Mortgage/Rental Payment ($):
Monthly Household Expenses ($):
Do you have any existing insurance policies? (What are they and who are they with):
Subscription Details
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