Lifestyle Insurance - Information Capture Form

When completing the Information Capture Form, or having your Insurance Advisor complete it on your behalf, you must provide all material facts. Failure to disclose such necessary information or disclose false information could invalidate any insurance cover in the event of a claim. Note to the Introducer: The Information Capture Sheet is provided for the purposes of capturing client’s cover requirements prior to producing a full quotation using the Source software. Submission to underwriters of an Information Capture Sheet is not an acceptable means of application. A fully completed Application Form produced from the Quotation Documentation section of the software and submitted electronically is the only acceptable means of submitting new business to underwriters for acceptance.

Applicant Details

Cover Details

Cover Commencement Date

The Property


By submitting this form, I confirm that the information given in this form is true, complete and accurate to the best of my knowledge.