You can always press Enter⏎ to continue
PERSONAL ACCIDENT & SICKNESS QUOTE FORM
Ten Seventy Pty Ltd t/a Reef Insurance Brokers is an Authorised Representative (AR # 1285127) of United Insurance Group (UIG) AFS Number 327131
lets go
1
YOU HAVE A DUTY OF DISCLOSURE OBLIGATION
*
This field is required.
Ok, so before we start we need to tell you some things... Yes, it's boring, but it’s important and we need to do this - it only takes a minute. YOUR DUTY OF DISCLOSURE Before you enter into an insurance contract, you have a duty to tell the insurer anything that you know, or could reasonably be expected to know, that may affect the insurer’s decision to insure you and on what terms. NOTE: You have this duty until the insurer agrees to insure you. You have the same duty before you renew, extend, vary, or reinstate an insurance contract. You do not need to tell the insurer anything that: • reduces the risk they insure you for; or • is common knowledge; or • the insurer knows, or should know; or • the insurer waives your duty to tell them about. IF YOU DO NOT TELL THE INSURER SOMETHING If you do not tell the insurer anything you are required to, they may cancel your contract, or reduce the amount they will pay you if you make a claim, or both. If your failure to tell the insurer is fraudulent, they may refuse to pay a claim and treat the contract as if it never existed. DUTY TO NOT MAKE A MISREPRESENTATION NOTE: if you are applying for a new consumer insurance contract, renewing a consumer insurance contract or varying an existing consumer insurance contract, which is an insurance policy obtained wholly or predominately in relation to personal, domestic or household insurance purposes, you must answer the specific questions asked by the insurer truthfully and accurately. In answering those questions, you must tell the insurer all information that’s known to you and that a reasonable person would be expected to provide in answer to the questions. APPLYING FOR A NEW CONSUMER INSURANCE CONTRACT OR VARYING AN EXISTING CONSUMER INSURANCE CONTRACT. • You have a duty under the Insurance Contracts Act 1984 (ICA) to take reasonable care not to make a misrepresentation to the insurer (your duty). • Your duty applies only in respect of a policy that is a consumer insurance contract, which is a term defined in the ICA. • Your duty applies before you enter into the policy, and also before you renew, extend, vary, or reinstate the policy. • Before you do any of these things, you may be required to answer questions and the insurer will use the answers you provide in deciding whether to insure you, and anyone else to be insured under the policy, and on what terms. To ensure you meet your duty, your answers to the questions must be truthful, accurate and complete. • If you fail to meet your duty, the insurer may be able to cancel your contract, or reduce the amount it will pay if you make a claim, or both. • If your failure is fraudulent, the insurer may be able to refuse to pay a claim and treat the contract as if it never existed.
I agree
I don’t agree
go back
sounds good - next
Submit
Press
Enter
2
When do you need your policy to start?
*
This field is required.
We can't back date policy, but we can change the start date - so if you are not sure - choose today...we can sort this out later.
-
Date
DD
MM
YYYY
go back
sounds good - next
Submit
Press
Enter
3
Are you...?
*
This field is required.
a Sole Trader or Contractor
an Employee
working Director
go back
sounds good - next
Submit
Press
Enter
4
You’re doing great! Please tell us your name?
*
This field is required.
First Name
Last Name
go back
sounds good - next
Submit
Press
Enter
5
What is your DOB?
if required
go back
sounds good - next
Submit
Press
Enter
6
What is your address?
*
This field is required.
We need a street address, not a PO Box please? That's the next question.
Street
Street Address
Suburb
Please Select
QLD
NSW
ACT
VIC
TAS
WA
NT
Please Select
Please Select
QLD
NSW
ACT
VIC
TAS
WA
NT
State
Post Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
go back
sounds good - next
Submit
Press
Enter
7
Do you have a postal address?
Leave this blank if you don't have a separate postal address.
go back
sounds good - next
Submit
Press
Enter
8
What’s your phone number?
*
This field is required.
This is kind of important - we need this one completed. We might need to call you.
Area Code
Phone Number
go back
sounds good - next
Submit
Press
Enter
9
What’s your email?
*
This field is required.
So we can email you your quote....
example@example.com
go back
sounds good - next
Submit
Press
Enter
10
Please tell us what you do - your occupation?
go back
sounds good - next
Submit
Press
Enter
11
What's your annual income?
*
This field is required.
This will be the income from your last tax return or what you expect to earn this year in total.
go back
sounds good - next
Submit
Press
Enter
12
Which covers do you want?
*
This field is required.
Accident - Work Hours only
Accident - 24/7 cover
Sickness and Accident - 24/7 cover
Agreed value $1000 /week income for Accident 24/7 cover
Agreed Value $1,200/week income for Accident 24/7 cover
go back
sounds good - next
Submit
Press
Enter
13
What waiting period do you want?
7 days
14 days
28 days
go back
sounds good - next
Submit
Press
Enter
14
Have you made any personal accident or sickness claims in the last 5 years?
No
Yes
go back
sounds good - next
Submit
Press
Enter
15
Ok, please tells us about your claim for accident and sickness?
We need info on what happened, how long your claimed for & the cost of the claim please.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
go back
sounds good - next
Submit
Press
Enter
16
Have you, in the past 5 years... been charged or convicted of a criminal offence, been prosecuted under any health and safety legislation (or similar) or been declared bankrupt or gone into liquidation or been refused insurance?
No
Yes
go back
sounds good - next
Submit
Press
Enter
17
We are going to need a few details and we might need to give you a call too.
e.g.: Lets start with the year and brief details of what happened and the outcome.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
go back
sounds good - next
Submit
Press
Enter
18
Do you want us to call you about any of the following policy types?
No strings attached - we can have a look at your other policies for you and provide a quote or explain what you are acutally covered for...what have your got to lose? Pick as many you like...
My Ute / Truck / Car
Management Liability + Employment Liability Insurance
Equipment or Machinery Breakdown
Mobile or Heavy Machinery Insurance
Income Protection + Trauma Insurance
Contract Works + Material Damage Insurance
Home / Renters or Landlords Insurance
No, thanks...I'm good
go back
sounds good - next
Submit
Press
Enter
19
Perfect...you’re all done! Before you hit that submit button please let us know where you heard about us?
A Friend
Yellow Pages
Facebook
Local Google Search
Existing Client
Other
go back
sounds good - next
Submit
Press
Enter
Should be Empty:
PERSONAL ACCIDENT AND SICKNESS QUOTE FORM
[Edit]
Question Label
1
of
19
See All
Go Back
Submit