PAS

Please fill in the required fields

First Name*

Surname*

Phone

Mobile Phone*

Street*

Suburb*

State*

Postcode*

Weekly Sum Insured*

Please note you can only cover yourself for up to 85% of your gross income

Gross Income

Email*

Height (cm)*

Please enter a number from 100 to 230.

Birth Date*

Weight (kg)*

You must be aged between 16 - 65 to apply for this insurance

If your BMI is above 30 or below 16, your policy quote will be sent for review

Age

Age Group

Accident Load

Price: $ 0.00 Quantity:

Accident Load - New

Sickness Load

Price: $ 0.00 Quantity:

Sickness Load - New

Gender*

Male
Female

Occupation*

Business Name

Occupation Class

Age Modifer

Price: $ 0.00 Quantity:

Class Modifier - New

Occupation Duties*

Has your weight altered by more than 10% in the last 12 months?*

Yes
No

You have answered Yes to your weight being altered. Please enter more details here.*

Are your duties hazardous? (e.g Explosives/dangerous substances, working from heights)*

Yes
No

You have answered Yes to hazardous duties. Please enter more details here.*

Review Required

Do you currently, or do you intend to engage in any hazardous pursuit or pastime, including but not limited to football of any code, boxing, rodeo activities, wrestling, martial arts, racing of any kind (other than on foot), motorsports, polo, water skiing, scuba diving or underwater activities, parachuting, parasailing, hang gliding, or other aerial activities, ski jumping, snow or ice sports, grass skiing, mountaineering, bungee jumping, abseiling, caving, shooting or training for or participating in professional sport of any kind. If “YES” please provide details.*

Yes
No

You have answered Yes to the question above. Please enter more details here*

Due to some of your answers, your quote will require a review, please complete all questions until the end to enable review consideration.

Please select an occupation before continuing.

Your policy start date -

BMI

Personal Accident and Sickness Insurance (Income Protection)

Step 1 of 7 - Policy Pre Registration - Step 1

Cover Type

105

Premium Funding Details