Apply Now (Obligation free)

All insurers require you to make a full declaration about your health, occupation and pastimes - but most insurers have application forms that are confusing and cumbersome to complete.

We've designed this EZiapplication system to make it easy for you to apply for Life Insurance products. The EZiapplication system will create an application for you and we'll post it to you for your review and update as necessary. Once you're satisfied with it's accuracy all you do is sign and return it to us.

Cover does not commence until the insurer has accepted your application, you've paid a premium, and your policy document has been issued.

Your application is risk-free. No deposit is required and there is no obligation to go ahead. Simply fill out the the form below and click "Send Application to EZibroker" to receive your free quote.

If you need assistance, please send an E-mail via the Contact page or call 1-800-89-77-49 with any questions you may have. Please also check out our FAQ page. You might find the answer to your question there.

Contact Details...

Questions marked * are 'required'

E-mail Address :- *

First Name :- *

Last Name :- *

Address Line 1 :- *

Address Second Line :-

Suburb :- *

Post Code :- *

Contact Telephone No. :- *

Personal Details...

Questions marked * are 'required'

Occupation :- *

Sex :- *

Male Female

Smoker :- *

No Yes

Average number of alcoholic drinks per week :- *

Height :- *

Date of Birth :- *

Weight :- *

Are you a permanent citizen of Australia :- *

No Yes

Do you intend to travel or live overseas :- *

No Yes

Do you have any other Life Insurance or
Trauma cover with another insurer :- *

No Yes

Has any other insurer ever refused you cover :- *

No Yes

Have you ever claimed from another insurer :- *

No Yes

Your Doctor Details...

Questions marked * are 'required'

Your Doctor or surgery name :- *

Surgery Address Line 1 :-

Surgery Address Line 2 :-

Suburb :- *

Postcode :-

Date of last consultation (approx.) :- *

Your health Details...

Questions marked * are 'required'

Gout, tendonitis, tenosynovitis :- *

No Yes

Arthritis, Bone Fracture, Joint Injury :- *

No Yes

Any Heart Condition, rheumatic fever, chest pain :- *

No Yes

High Blood Pressure, raised cholesterol, vein or circulatory disorder :- *

No Yes

Cancer or Tumour of any kind :- *

No Yes

Breast lump or growth of any kind:- *

No Yes

Cyst, Mole or Skin lesion :- *

No Yes

Anaemia, leukaemia, haemophilia :- *

No Yes

Asthma, Bronchitis, lung condition, breathing or respiratory disorder :- *

No Yes

Breathing or respiratory disorder, Sleep apnoea :- *

No Yes

Disorder of the kidney, bladder or prostate :- *

No Yes

Urinary complaint or kidney stone :- *

No Yes

Back or neck disorder, spinal condition Sciatica, Whiplash:- *

No Yes

Mental Illness, Depression, anxiety, nervous disorder :- *

No Yes

Stress or post traumatic stress disorder :- *

No Yes

Chronic Fatigue, chronic pain syndrome :- *

No Yes

Fibromyalgia, fibrositis, myalgia :- *

No Yes

Diabetes, abnormal blood sugar levels :- *

No Yes

Thyroid disorder :- *

No Yes

Indigestion, gastric or duodenal ulcer, hernia :- *

No Yes

Bowel disorder, irritable bowel syndrome:- *

No Yes

Gall bladder or liver disorder, Hepatitis :- *

No Yes

Epilepsy, Stroke, headaches, migraines :- *

No Yes

Disorder of the brain or nervous system :- *

No Yes

Dizziness or fainting, memory loss :- *

No Yes

Disorder of the ears, eyes or speech :- *

No Yes

Psoriasis, eczema, dermatitis or other skin condition :- *

No Yes

Sexually transmitted disease or infection :- *

No Yes

Any other illness or disability no previously mentioned :- *

No Yes

If not already mentioned above, have you ever needed
hospital admission or treatment :- *

No Yes

In the last 5 years have you needed any medical tests
of any nature (including X-Ray or genetic) :- *

No Yes

Used or currently using any prescribed medication :- *

No Yes

Any other illness, disease, illness, operation, disability
or hospitalisation not already mentioned :- *

No Yes

Been unable to work in your occupation for longer than
3 days because of an illness or injury :- *

No Yes

Consulted any other provider of medical services for any reason :- *

No Yes

Contemplate or intend to seek medical advice or treatment for
any condition, including surgery or tests in the near future :- *

No Yes

Do you participate in Aviation other than as a
fare-paying passenger on a licensed public service :- *

No Yes

Participate in Motor racing, Underwater Diving :- *

No Yes

Motor Bike riding, Trail Bike riding, any off-road riding :- *

No Yes

Any other hazardous activity or pastime :- *

No Yes

Life Insurance cover required :- * $

Females Only ...

Have you ever had any complications with pregnancy or childbirth? :-

No Yes

Are you currently pregnant? :-

No Yes

Have you ever had an abnormal breast ultrasound or mammogram? :-

No Yes

Have you ever had an abnormal pap smear :-

No Yes

Created By Writer From Oz

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