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 Brokers National 

Term Life cover provides a lump sum payment to your family due to death                                                  Policy covers death from any natural cause                                                        Cover for death extends worldwide                                                      Optional covers can also be included in the same policy: Trauma Recovery, Total & Permanent Disablement, Income Protection, & Business Expenses                                                          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 Term Life Insurance Quote


 Thank you for considering our on-line term life insurance quote service. Brokers National has accounts with most insurers and underwriting agencies. We aim to find you the best term life 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.

 

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

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 term life optional covers are also available:
Term Life protection: $ Sum insured
Optional Total & Permanent Disablement: $ Sum insured
Optional Trauma Recovery protection: $ Sum insured

If you are also 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 also 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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