health insurance brokers

Please complete all sections of the following evaluation form.
For more information click on

or hover your cursor over the Underlined words.

Personal Detail

Are you entitled to full medicare benefits? YES NO

» (Please click here and complete the evaluation form for international visitors)

Title
First Name
Last Name
Address
Suburb
State
Post Code
Date of Birth	(yyyy)
Home Phone
Mobile Phone
Work Phone
Email Address
Gender
Marital Status

Is your partner entitled to full medicare benefits? YES NO

» (Please click here and complete the evaluation form for international visitors)

Do you earn over $50,000 per year? YES NO

Is your family income over $100,000 per year? YES NO

Do you and your partner earn over $100,000 per year? YES NO

Person(s) to cover

Partner's Date of Birth
Partner's Gender

Number of Children

Child 1 Date of Birth:

Child 2 Date of Birth:

Child 3 Date of Birth:

Child 4 Date of Birth:

Child 5 Date of Birth:

Child 6 Date of Birth:

Child 7 Date of Birth:

Child 8 Date of Birth:

Child 9 Date of Birth:

Child 10 Date of Birth:

Child 11 Date of Birth:

Child 12 Date of Birth:

Child 13 Date of Birth:

Child 14 Date of Birth:

Child 15 Date of Birth:

Cover Required

Please select the types of cover you require and then select your specific cover requirements for each type of cover selected.

Hospital Cover
Extras Cover
Ambulance Cover

Hospital Cover
All our recommended hospital cover products pay benefits for the majority of conditions that require hospitalisation.
To reduce your premiums you can choose to exclude the following services, which you may not require.

Include	Exclude	Hospital Cover
		» Pregancy and Obstetrics
		» Assisted Reproduction
		» Coronary Care
		» Hip and Knee Replacement
		» Knee Reconstruction
		» Major Eye Surgery
		» Psychiatric Therapy
		» Medically required cosmetic surgery

Excess
Please select the maximum excess you are prepared to pay to reduce your hospital premium.

Extras Cover
To get the best value from your extras cover only select cover for benefits you will definitely use over the next 12 months

Dental - General
Optical
Physiotherapy
Oral Surgery -Major Dental
Endodontics - Major Dental
Periodontics - Major Dental
Crowns and Bridges - Major Dental
Dentures - Major Dental
Orthodontics - Major Dental
Osteopathy/Chiropractic
Homeopathy/Naturopathy/Acupuncture
Remedial Massage
Podiatary
Dietetics
Pharmaceutical
Blood Glucose Monitor
Hearing Aids
Home Nursing
Nebuliser Pump
Occupational Therapy
Psychology
Speech Therapy
Health Improvement Programs
OTHER

Lifetime Health Cover Loading

Your Loading
Your premium will not be effected by lifetime health cover loading

Your Loading
Have you had hospital cover continuously since 1 July 2000? YES NO

Your Loading
Have you had hospital cover continuously since turning 31? YES NO

Your Partner Loading
Your partner's will not be effected by lifetime health cover loading

Your Partner Loading
Has your partner had hospital cover continuously since 1 July 2000 YES NO

Your Partner Loading
Has your partner had hospital cover continuously since turning 31YES NO

Current Cover Detail

Do you currently hold health insurance? YES NO

Does your partner currently hold health insurance? YES NO

Your Insurance Information

Membership Type:
Which fund is it?
Level of hospital:
Level of extras:
Approximate premium:
Payment period:
Rebate included?	YES NO

Is your partner included in this cover? YES NO

Your Partner's Insurance Information

Membership Type:
Which fund is it?
Level of hospital:
Level of extras:
Approximate premium:
Payment period:
Rebate included:	YES NO

Budget and Further Info

What is your current budget:	Paid
Include tax rebate?	YES NO
Additional Info:
How did you hear about us?