How many policies would you like to check?
Submitters Name
If you are an Adviser enquiring on behalf of a client, please tick the box
Life Insurance Company
Is it a Whole of Life or Endowment policy?
Policy Start Date
Current Age of Life Insured
Current Age of Joint Life Insured (if any)
Maturity Date (Endowment policies only)
Sum Insured
Accumulated Reversionary (Annual) Bonuses
Please enter '0' if there are none.(Note: If there are no bonuses then it is unlikely to be a policy we can make an offer on)
Gross Surrender value quoted by Life Co. as at today's date
Please enter '0' if there are none.(This is the value before any policy premium or loan debts are deducted)
Are you aware of any excluded activities not covered by your policy?Exclusions normally relate to dangerous activities which you may be involved in, e.g. mountaineering or flying
Are you aware of any riders attaching to your policy?Riders relate to specific health conditions covered under your policy, or additional cover, for which you pay an additional premium.
Where did you hear about us?
Please provide more information
What is your primary reason for cashing in your policy/s?
Please provide more information
Obtain a no obligation quote
Email Address
Phone Number
Policy Number

Is your policy jointly insured?

Details of Life Insured
Surname
First name
Middle name
Date of Birth

Is your policy jointly owned?

Details of Policy Owner
Surname
First name
Middle name
Address of Policyowner
Street or Road name and no.
Suburb
Rural R D number
City/Town
Postcode
Gross Surrender Value quoted by Life Co. as at today's date
Value of any premium or loan debts quoted by Life Co. as at today's date
(enter zero if there are none)
Net Surrender Value quoted by Life Co. as at today's date
Premium Amount
Premium Frequency
Are you aware of alterations to the policy in the last 10 years?
Are you aware of inflation or CPI adjustments to the sum insured since start date?
It is important that you complete the form accurately, as any settlement documentation will be drawn up using this information.
If you have any problems submitting the information, please do not hesitate to call us on freephone 0800 476 542.