Make sure your Life Insurance is in force when it's needed while paying the minimum cost for it over the long term - guaranteed

Home About D.I.Y Quote Life Insurance Premium Trap Apply Now D.I.Y Cover Online FAQ Contact

Apply Now for a 'quote' - Obligation free - no deposit required.

All insurers require you to make a full declaration about your health, occupation and pastimes - but most insurers have application forms that are confusing and cumbersome to complete.

We've designed this EZiapplication system to make it easy for you to apply for Life Insurance products. The EZiapplication system will create an application for you and we'll post it to you for your review and update as necessary. Once you're satisfied with it's accuracy all you do is sign and return it to us.

Cover does not commence until the insurer has accepted your application, you've paid a premium, and your policy document has been issued.

Your application is risk-free. No deposit is required and there is no obligation to go ahead. Simply complete the application below and click 'Send Application' button at the bottom of the page to receive your free quote by e-mail.

If you need assistance or have any questions just send us an e-mail via the Contact page or call (1800) 89-77-49 with any questions you may have. Please also check out our FAQ page. You might find the answer to your question there.
__________Your contact Details... Questions marked * are 'required'
E-mail Address :- _ * _ 1
First Name :- _ * _ 2
Last Name :- _ * _ 3
Address Line 1 :- _ * _ 4
Address Line 2 :- ____
Suburb :- _ * _ 5
Post Code :- _ * _ 6
Contact phone :- ____ 7

back to top
__________Personal ... Questions marked * are 'required'
Occupation :- _ * _ 8
Sex :- _ * _ __Male __Female 9
Smoker :- _ * _ __No __Yes 10
Average Number of Alcoholic drinks per week :- _ * _ 11
Height :- _ * _ 12
Weight :- _ * _ 13
Date of Birth :- _ * _ 14
Are you a permanent resident of Australia? :- _ * _ __No __Yes 15
Life Insurance cover required :-_ $ _ 16
Do you intend to work or reside overseas in the near future? :- _ * _ __No __Yes 17
Do you have any Life Insurance with any insurer? :- _ * _ __No __Yes 18
Has any previous application for life insurance ever been________
denied, postponed or modified (e.g. premium loaded)? :- _ * _ 		__No __Yes 19

back to top
__________Your Doctor Details... Questions marked * are 'required'
Your doctor's name or Surgery name :- _ * _ 20
Address Line 1 :- _ * _ 21
Address Line 2 :- ____ 22
Suburb :- _ * _ 23
Post Code (if known) :- ____ 24
Surgery phone no. (if known) :- ____ 25
Approximate date of last consultation :- ____ 26
Reason for consultation :- ____ 27

back to top
__________Your health ... Questions marked * are 'required'
Have you ever had, been told you had - or received medical advice or treatment for ... ?
Gout, tendonitis, tenosynovitis :- _ * _ __No __Yes 30
Arthritis, Bone Fracture, Joint Injury :- _ * _ __No __Yes 31
Any Heart Condition, rheumatic fever, chest pain :- _ * _ __No __Yes 32
High Blood Pressure, raised cholesterol,______
vein or circulatory disorder :- _ * _ 		__No __Yes 33
Cancer or tumour of any kind :- _ * _ __No __Yes 34
Breast lump or growth of any kind :- _ * _ __No __Yes 35
Cyst, Mole or Skin lesion :- _ * _ __No __Yes 36
Anaemia, leukaemia, haemophilia :- _ * _ __No __Yes 37
Asthma, Bronchitis, lung condition,______
breathing or respiratory disorder :- _ * _ 		__No __Yes 38
Breathing or respiratory disorder, Sleep apnoea :- _ * _ __No __Yes 39
Disorder of the kidney, bladder or prostate :- _ * _ __No __Yes 40
Urinary complaint or kidney stone :- _ * _ __No __Yes 41
Back or neck disorder, spinal condition Sciatica, Whiplash :- _ * _ __No __Yes 42
Mental Illness, Depression, anxiety, nervous disorder :- _ * _ __No __Yes 43
Stress or post traumatic stress disorder :- _ * _ __No __Yes 44
Chronic Fatigue, chronic pain syndrome :- _ * _ __No __Yes 45
Fibromyalgia, fibrositis, myalgia :- _ * _ __No __Yes 46
Diabetes, abnormal blood sugar levels :- _ * _ __No __Yes 47
Thyroid disorder :- _ * _ __No __Yes 48
Indigestion, gastric or duodenal ulcer, hernia :- _ * _ __No __Yes 49
Bowel disorder, irritable bowel syndrome :- _ * _ __No __Yes 50
Gall bladder or liver disorder, Hepatitis :- _ * _ __No __Yes 51
Epilepsy, Stroke, headaches, migraines :- _ * _ __No __Yes 52
Disorder of the brain or nervous system :- _ * _ __No __Yes 53
Dizziness or fainting, memory loss :- _ * _ __No __Yes 54
Disorder of the ears, eyes or speech :- _ * _ __No __Yes 55
Psoriasis, eczema, dermatitis or other skin condition :- _ * _ __No __Yes 56
Sexually transmitted disease or infection :- _ * _ __No __Yes 57
Any other illness or disability not previously mentioned :- _ * _ __No __Yes 58
If not already mentioned above,______
have you ever needed hospital admission or treatment :- _ * _ 		__No __Yes 59
In the last 5 years have you needed any medical test______
of any nature (including X-Ray or genetic) :- _ * _ 		__No __Yes 60
Have you used in the past or are you currently using______
any prescribed medication :- _ * _ 		__No __Yes 61
Have you ever experienced any other illness,______
disease or injury, operation, disability or hospitalisation______
not already mentioned :- _ * _ 		__No __Yes 62
Have you ever been unable to work in your occupation______
for longer than 3 days because of an illness or injury :- _ * _ 		__No __Yes 63
Other than already mentioned have you ever consulted______
any provider of medical services for any reason :- _ * _ 		__No __Yes 64
Are you contemplating or do you intend to seek______
medical advice or treatment for any condition,______
(including minor surgery or tests), in the near future :- _ * _ 		__No __Yes 65

back to top
__________Your pastimes... Questions marked * are 'required'
Do you participate in Aviation other than as a______
fare-paying passenger on a licensed public service :- _ * _ 		__No __Yes 70
Participate in Motor racing, Underwater Diving :- _ * _ __No __Yes 71
Motor Bike riding, Trail Bike riding, any off-road riding :- _ * _ __No __Yes 72
Any other hazardous activity or pastime :- _ * _ __No __Yes 73

back to top
__________Females only ... Questions marked * are 'required'
Have you ever had any complications______
with pregnancy or childbirth? :- _ * _ 		__No __Yes 80
Are you currently pregnant? :- _ * _ __No __Yes 81
Have you ever had an abnormal______
breast ultrasound or mammogram? :- _ * _ 		__No __Yes 82
Have you ever had an abnormal pap smear? :- _ * _ __No __Yes 83

back to top

Synchron Logo

 This website provides information of a GENERAL nature only. No recommendation is made about
the suitability of any of the insurance products described here to your own situation or needs.
You should obtain and consider the relevant 'Product Disclosure Statement' or policy wording for a
financial product before making any decision about whether to acquire or not acquire that product.
Download your Synchron Financial Service Guide HERE
Designed by Writer From Oz