Laurence Anderson
Area Manager
Finance Lending & Insurance
Mobile +61 414 444 196
P.O.BOX 4174, BURWOOD EAST, 3151 VICTORIA, AUSTRALIA
FINANCIAL SERVICES ENQUIRY
From
Date
DD slash MM slash YYYY
Customer Details
Existing client for:
(no. of years)
Name
First
Last
Company Name
Contact Phone
Occupation
Email
Age next birthday
Date of Birth
DD slash MM slash YYYY
Sex
Male
Female
Smoker
Yes
No
Marital Status
Single
Married
De Facto
Divorced
Widowed
Number of dependents
Income
If White Collar – University Educated?
Yes
No
If Blue Collar – Type of Duties and Percentage Manual Work:
Level of assets
Level of debts
How long could you financially manage without any regular income?
Less than a month
1-6 months
1-3 years
Over 3 Years
Any Pre-Existing Medical Conditions
Please provide a quotation for
Life
Superannuation
Income replacement
Life Insurance
Specify Amount
Trauma Cover
TPD
Superannuation
Monthly Contributions
To start with
Existing Funds
Personal Income Replacement
Per Month
Waiting Period
(days)
Current Annual Income (including Tax)
But excluding GST
Broker Notes
Does the client have a Will?
Yes
No
Is the client self employed
Yes
No
Authority to Access form attached?
Accepted file types: doc, pdf, docx, Max. file size: 8 MB.
Adviser Transfer Form Attached?
Accepted file types: doc, pdf, docx, Max. file size: 8 MB.
Δ
Scroll to top