SwitchSelect

Title
First name	* Your first name is required.
Last name	* Your last name is required.
Date of birth	^*
Street address	* Current Address is required.
Suburb	* Current Suburb is required.
State
Postcode	* Current Postcode is required.

Email address
Daytime phone number	^* Your phone number is required.
Evening phone number	^* Your after hours number is required.
Mobile number
Preferred time to receive call (AEST)

When would you like your cover in place?

Are you a smoker?

Yes

Gender

Male

Female

Occupation

Industry

Term Life Cover
(Lump sum on death)

$^* Examples

Do you require TPD cover?
(Lump sum for permanent disablement)

$ Examples

Do you require trauma cover?
(Lump sum on diagnosis of specific conditions)

$ Examples

Do you require income protection insurance?
(Replaces your income should you be unable to work due to injury or sickness)

Yes

Current annual income
(Please note most insurance companies limit the amount of income protection insurance cover to 7% of your annual income)

Additional Comments

Password

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Switchselect Guarantee

Founder Leon Hayes
gives you the
Switchselect
Guarantee:

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