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 Brokers National 

Income Protection cover is essential for all employed people especially those people that have their own businesses & not protected by workcover                                             Not only does it cover you for Accident, but it also extends to include Sickness                                         Accident & Sickness is covered 24 hours a day & not just working hours                                                You have a choice of waiting periods and benefit periods to select                                            Optional covers can also be included in the same policy: Business Expenses, Term Life, Total & Permanent Disablement, or Trauma Recovery                                               Simply complete the form below                                             We will also meet you face to face outside business hours to answer questions & help you fill out the paperwork

On-Line Income Protection Insurance Quote


Thank you for considering our on-line income protection insurance quote service. Brokers National act as multi agents for life risk products. We aim to find you the best income protection insurance deal possible.

Please fill in the following form - answering all questions, then either:

1. Click on "Email to Brokers National" at the bottom of this form.  OR                               

2. Highlight this form to "Print It" and then "Fax It" to our office on 03 9791 6633.


 Use the Mouse or the Tab key to move to the next field. We will respond with quotes as soon as they have been received from our insurers.

Income Protection & Business Expenses (& Optional Life, TPD,Trauma)

Personal details:

Your Name:
Gender: Male    Female
Date of birth:  
Do you smoke? Yes    No
Occupation:

Duties  / Work You Do / Responsibilities:

Any recent Health problems?


In addition to income protection optional covers are also available:
Optional Term Life protection: $ Sum insured
Optional Total & Permanent Disablement: $ Sum insured
Optional Trauma Recovery protection: $ Sum insured

If you are seeking income protection:
Monthly gross salary before tax: $ per month
Monthly cover (maximum 75% of salary): $ per month
Waiting period requested (days): 14    30 (Recommended)   90   Excess
Cover period in years (Accident/Sickness): 2/2       5/5       60/60       65/65

If you are seeking optional cover for fixed business expenses:
Monthly gross fixed business expenses: $ per month (eg. vehicle repayments)
Waiting period requested (days): 14    30 (Recommended)   90    Excess
Cover period in years (Accident/Sickness): 2/2       5/5       60/60       65/65

Any other comments, requests or relevant information you need to add:


Contacting you about your quote:

Please make sure you leave a contact phone number and the best time to call you.
Your Name:
Company name:
Your Phone Number & Area Code:
Best Time(s) To Call:
Please send my quote by (select at least one): email     phone     fax     mail
Your Email:
Your Facsimile:
Your Postal Address:

Click On Email Quote To Send         Form To Us
 

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