Bronson Financial Services - Insurance Quote

1. Please fill out all of the required information and click "Submit" at the end of the page.

First Name Required Question

Last Name

Date of Birth Required Question

Occupation Required Question

Email address (Where we can send the quote) Required Question

Contact number

2. Are you an Employee, Sole Trader, Partner or employed by own company: Required Question

3. What are the principal duties of your occupation? Required Question

4. How long have you worked in this occupation? Required Question

5. Where do you perform these duties? (local, interstate, overseas) Required Question

6. Do you perform manual work either regularly or occasionally, and if so, what percentage? Required Question

7. Do you hold qualifications? eg. – tradesman / degrees etc. If so, please provide details. Required Question

8. Do you earn income from a second occupation? Required Question

	Yes
	No

9. What were the principal duties of your previous occupation? Required Question

10. How long did you work in this occupation? Required Question

11. If you were unable to work due to illness or injury, would your business continue to operate? Required Question

	Yes
	No

12. If “yes” will you continue to receive, or be entitled to receive, any income from the business?
(eg: salary, wages, director’s fees, distributions, dividends or net profit)
Required Question

	Yes
	No

13. If “yes”, estimated amount $ Required Question

14. Expected duration? Required Question

15. Income -
Required Question

	Last Financial Year $	Preceding Year $
Gross Income / Turnover of Business
Gross Business Expenses
Net Income of Business
Taxable Income of Director / Partner

16. Health Details Required Question

Height (cm)
Weight (Kg)

17. Do you smoke? Required Question

	Yes
	No

18. Do you have any symptoms of ill health or injury or are you taking any prescribed medication of any kind? Required Question

	Yes
	No

19. Have you consulted or received medical advice from any doctor, undergone any medical examinations, tests or treatment, been in hospital or suffered any physical disability within the past 12 months? Required Question

	Yes
	No

20. Have you ever received medical advice or been diagnosed as suffering from or had treatment for any heart complaint, stroke, cancer or tumour of any type, blood pressure, anxiety, depression or nervous disorder? Required Question

	Yes
	No

21. In the last 12 months have you taken part or do you have definite intentions to take part in any organised sport or hazardous activity eg, football, parachuting, hang gliding, motor sport of any kind, underwater diving, rock climbing, paragliding, caving, mountaineering, ocean racing, martial arts, rodeo, aviation other than as a fare paying passenger on a licensed service? Required Question

	Yes
	No

22. Have you ever had an application on your life declined, postponed, accepted with a higher premium or special conditions, or otherwise as submitted? Required Question

	Yes
	No

23. Please give details of any “yes” answers from the above questions. Required Question

24. What type of personal insurance cover are you looking for? Required Question

	Life Insurance
	Total and Permanent Disablement Cover
	Trauma Cover
	Income Protection