This field is hidden when viewing the formTracking IDThis field is hidden when viewing the formAdvisor NameThis field is hidden when viewing the formAdvice TypePersonal Details Name First Middle Last Date of Birth GenderMaleFemaleOtherMarital StatusMarriedDefactoCivil UnionEmail PhoneNationality AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands – Country of Birth AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands – Residency— Please Select —CitizenPermanent ResidentVisaCurrent Address Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Living Situation— Please Select —RentBoardOwnOtherMonths at AddressYears at AddressDo you have a Will in place? Yes No Any personal guarantees in place? Yes No Smoker Yes No Height (cm)Weight (kg)BMIDependentsFull NameAge Add RemoveAssetsCar, Boat, Furniture, Art, Savings, Art, Jewlery etc.TypeValue Add RemoveLiabilitiesCredit cards, Vehicle finance, Student loan, Personal loanse etc.TypeValue Add RemoveClient Details NotesWork & Finances Employment Status— Please Select —Full TimePart TimeSelf EmployedUnemployedRetiredStudentBusiness/Employer NameIndustry TypeOccupationTime at Role (Months)Hours per WeekAnnual SalaryIncome Source— Please Select —Salary/WagesSelf EmployedOtherOccupation Class— Please Select —Class 1Class 2Class 3Class 4Class 5Not ApplicableAvailable Sick DaysAvailable Annual LeaveKiwiSaver BalanceContribution Rate— Please Select —3%4%6%8%10%ProviderWould you like to organise a review of your KiwiSaver? Yes No Later Mortgage AmountWeekly RepaymentsLenderWork & Finances NotesHousehold Expenses Groceries ($)Groceries (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formGroceries (Annual Total)Clothing ($)Clothing (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formClothing (Annual Total)Transport ($)Transport (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formTransport (Annual Total)Utilities ($)Utilities (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formUtilities (Annual Total)Internet ($)Internet (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formInternet (Annual Total)Phone ($)Phone (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formPhone (Annual Total)Medical Expenses ($)Expenses (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formMedical Expenses (Annual Total)Rent ($)Rent (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formRent (Annual Total)Rates ($)Rates (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formRates (Annual Total)General Insurance ($)General Insurance (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formGeneral Insurance (Annual Total)Vehicle Insurance ($)Vehicle Insurance (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formVehicle Insurance (Annual Total)Education ($)Education (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formEducation (Annual Total)Childcare ($)Childcare (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formChildcare (Annual Total)Pet Care ($)Pet Care (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formPet Care (Annual Total)Pay TV & Streaming ($)Pay TV & Streaming (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formPay TV & Streaming (Annual Total)Recreation & Entertainment ($)Recreation & Entertainment (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formRecreation & Entertainment (Annual Total)Tithing ($)Tithing (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formTithing (Annual Total)Other ($)Other (Frequency) Weekly Fortnightly Monthly Yearly This field is hidden when viewing the formOther (Annual Total)Total Household Expenses These totals are calculated by converting all expense items to a common frequency based on their selected payment periods (weekly, fortnightly, monthly, or yearly). WeeklyFortnightlyMonthlyYearlyMedical History Health IssueFirst Symptoms Date Current Terms— Please Select —NoneExcludedLoaded50% Loading75% Loading100% Loading150% Loading200% Loading250% Loading300% LoadingNotesAdd Medical History Yes No Health IssueFirst Symptoms Date Current Terms— Please Select —NoneExcludedLoaded50% Loading75% Loading100% Loading150% Loading200% Loading250% Loading300% LoadingNotesAdd Medical History Yes No Health IssueFirst Symptoms Date Current Terms— Please Select —NoneExcludedLoaded50% Loading75% Loading100% Loading150% Loading200% Loading250% Loading300% LoadingNotesAdd Medical History Yes No Health IssueFirst Symptoms Date Current Terms— Please Select —NoneExcludedLoaded50% Loading75% Loading100% Loading150% Loading200% Loading250% Loading300% LoadingNotesAdd Medical History Yes No Health IssueFirst Symptoms Date Current Terms— Please Select —NoneExcludedLoaded50% Loading75% Loading100% Loading150% Loading200% Loading250% Loading300% LoadingNotesFamily History –Health IssueRelationshipAge at Diagnosis Add RemoveCurrent Insurance Insurance API (Annual Premium Income) Total insurance premiums calculated at different payment frequencies based on all current policies. WeeklyFortnightlyMonthlyYearlyProduct Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProviderAsteronFidelity LifeNIBPartners LifeSovereign— Please Select —ACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance Notes Ready to Submit? Please take a moment to review all of the information you’ve entered. If you need to make any changes, just click the “Previous” button below to go back through the form and update any answers. Once you’re happy, click “Submit” to finalise this Fact Find. This field is hidden when viewing the formTracking IDThis field is hidden when viewing the formAdvisor NameThis field is hidden when viewing the formAdvice TypePersonal Details Name First Middle Last Date of Birth GenderMaleFemaleOtherEmail PhoneNationality AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands – Country of Birth AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands – Residency— Please Select —CitizenPermanent ResidentVisaSame address as partner? Yes No Current Address Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Living Situation— Please Select —RentBoardOwnOtherMonths at AddressYears at AddressDo you have a Will in place? Yes No Any personal guarantees in place? Yes No Smoker Yes No Height (cm)Weight (kg)BMIDependentsFull NameAge Add RemoveAssetsCar, Boat, Furniture, Art, Savings, Art, Jewlery etc.TypeValue Add RemoveLiabilitiesCredit cards, Vehicle finance, Student loan, Personal loanse etc.TypeValue Add RemoveClient Details NotesWork & Finances Employment Status— Please Select —Full TimePart TimeSelf EmployedUnemployedRetiredStudentBusiness/Employer NameIndustry TypeOccupationTime at Role (Months)Hours per WeekAnnual SalaryIncome Source— Please Select —Salary/WagesSelf EmployedOtherOccupation Class— Please Select —Class 1Class 2Class 3Class 4Class 5Not ApplicableAvailable Sick DaysAvailable Annual LeaveKiwiSaver BalanceContribution Rate— Please Select —3%4%6%8%10%ProviderWould you like to organise a review of your KiwiSaver? Yes No Later Mortgage AmountWeekly RepaymentsLenderWork & Finances Notes Shared Household Expenses This section is shared with Client 1’s household expenses. You do not need to re-enter anything here — please continue to the next section. Medical History Health IssueFirst Symptoms Date Current Terms— Please Select —NoneExcludedLoaded50% Loading75% Loading100% Loading150% Loading200% Loading250% Loading300% LoadingNotesAdd Medical History Yes No Health IssueFirst Symptoms Date Current Terms— Please Select —NoneExcludedLoaded50% Loading75% Loading100% Loading150% Loading200% Loading250% Loading300% LoadingNotesAdd Medical History Yes No Health IssueFirst Symptoms Date Current Terms— Please Select —NoneExcludedLoaded50% Loading75% Loading100% Loading150% Loading200% Loading250% Loading300% LoadingNotesAdd Medical History Yes No Health IssueFirst Symptoms Date Current Terms— Please Select —NoneExcludedLoaded50% Loading75% Loading100% Loading150% Loading200% Loading250% Loading300% LoadingNotesAdd Medical History Yes No Health IssueFirst Symptoms Date Current Terms— Please Select —NoneExcludedLoaded50% Loading75% Loading100% Loading150% Loading200% Loading250% Loading300% LoadingNotesFamily History –Health IssueRelationshipAge at Diagnosis Add RemoveCurrent Insurance Insurance API (Annual Premium Income) Total insurance premiums calculated at different payment frequencies based on all current policies. WeeklyFortnightlyMonthlyYearlyProduct Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProvider— Please Select —AsteronFidelity LifeNIBPartners LifeSovereignACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance NotesAdd Current Insurance? Yes No Product Type— Please Select —LifeTraumaTPDIncome ProtectionHealthMortgageWaiver of PremiumRedundancyCancer CareProviderAsteronFidelity LifeNIBPartners LifeSovereign— Please Select —ACCAccuroAMPANZAxaBNZGreenwichKiwibankSouthern CrossTBCTowerWestpacPolicy NumberSum AssuredPremiumFrequency— Please Select —WeeklyFortnightlyMonthlyBiannuallyAnnuallyThis field is hidden when viewing the formPremium (Annual Amount)Current Insurance Notes Ready to Submit? Please take a moment to review all of the information you’ve entered. 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