On-line Life Insurance



Thank you for considering our on-line life insurance service. Because Greater National Group is an insurance broker, not an insurance company, we will process your application with major insurance companies and find you competitive insurance terms.

Please fill in the following form as fully as possible, then click 'submit' at the end of the form.
You can use the TAB key to move to the next field. We will respond with your terms as soon as we have researched the market.


Personal details:
1a. Gender:
Male Female
1b. Date of birth:  
1c. Do you smoke?
Yes No
1d. Occupation:
1e. Your current height:  
1f. Your current weight:  
About the value of insurance you are seeking:
2a. Term protection: $
2b. Term / TPD protection: $
2c. Trauma protection: $
If you are seeking income protection:
3a. Monthly salary: $
3b. Monthly cover (max 75% of salary): $
3c. Waiting period requested (days):
14 30 90
3d. Cover period:
2/2 5/5 65/65


Duty of Disclosure:
Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?
Yes No
If so, please provide details:
I/We hereby declare that:
My/Our attention has been drawn to the Important Notices accompanying this form and further I/we have read these notices carefully and acknowledge my/our understanding of their content. The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this form and the inception date of the insurance to which this relates I/we shall give immediate notice thereof. I/We authorise GNG and the Insurer to collect or disclose any personal information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact and the Privacy Policy. I/We also confirm that I/we am/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this form and I/we complete this form on their behalf.
Any other comments, requests or relevant information you need to add:
Contacting you about your quote:
In order to select the most appropriate cover for you, it may be important to discuss quote details in person. Please leave a contact phone number and best time to call to facilitate this.
Your full name:
Company/Business/Name of Applicant to be Insured:
ABN:
Your phone number (please include area code):
Your mobile phone number:
Best time(s) to call:
Please send my quote by (select at least one):
email phone fax mail
Your email address:
Your website address:
Your fax number:
Your postal address:
Country: