| 1. Who is to be insured on the policy ? |
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| 2. What type of insurance do you require ? |
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| 3. How much cover do you want (Sum Assured) ? |
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4. How long do you want the cover to last (Term) ?
Minimum term 30 days |
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| 5. When do you want the policy to start ? |
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| 6. How many Pre-Existing Medical Conditions are to be covered ? Total conditions for all insured |
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If the first person insured has two (2) conditions and the second person one (1) condition, select three (3) |
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| 7. Do you, or anybody to be insured on the policy have a Hazardous Occupation ? |
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| 8. Do you or, anybody to be covered on the policy work or live in a Hazardous Location or Country ? |
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| 9. If necessary please use the box below to enter any other details about the type of insurance you want |
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