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1 George Street,
Newmarket,
Auckland 1023

info@elan.co.nz
(09) 268 4140

Name

First Name

Last Name

Mobile

Date of Birth

YYYY

Sex

Smoker

I am interested in

Life Insurance

Health Insurance

Income Insurance

Trauma Insurance

Key Person Insurance

Kiwisaver Review

The following section is for those who know how much insurance they require, we can analyse your situation and advise suitable amounts as well, in which case leave blank.

Life Insurance Amount

Trauma Insurance Amount

Annual Salary/Income

(Used for Income Insurance purposes)

Health Insurance Excess

(The amount you pay up to when making a health insurance claim. If you have significant savings select a higher excess.)

Partner (Optional)

First Name

Last Name

Date of Birth

YYYY

Sex

Smoker

Additional Info

Any extra information that might help us understand your situation. e.g. level of debt/savings, children, current cover, medical issues.

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