Personal Accident & Illness Insurance Quote
Your Details
Full name: (incl Title)
*
Contact telephone number:
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Email address:
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Date of Birth
Address:
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Postcode:
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Occupation (fully describe):
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Gross annual salary $:
*
Employment Status:
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Please Select
Self-Employed less than 12 months - No Work Cover
Self-Employed more than 12 months - No Work Cover
Employed - Covered by Work Cover
Insurance Requirements
Type of cover required:
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Accident & Illness
Accident Only
Capital Benefit (Lump Sum)
Required weekly benefit $:
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Required capital benefit $:
Please use this box to provide any further information that may be relevant to your Insurance policy (including any previous claims, accidents or illnesses):
*
If none, please state
Current Insurance provider:
*
If none, please state
Current Insurance premium:
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If none, please state
Renewal date of existing insurance/date cover to start (as applicable):
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NB: Cover is not in force until agreed upon by the company
Contacting You
Are you an existing Trades Essentials customer?
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yes
no
Preferred contact method:
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Please select
Telephone
Email
Letter
Preferred contact time:
Please select
No preference
08:00-10:00
10:00-12:00
12:00-14:00
14:00-16:00
16:00-18:00
How did you hear about us?
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Please select
Google search
Referred by friend
Referred by another business
Referred by another website
Search engine
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