Your Name D.O.B
Occupation Self Employed
  Over 3 yearsYes  No
Are you a smoker  Yes  No
Partner D.O.B
Occupation Self Employed
  Over 3 yearYes  No
Are you a smoker  Yes  No
Children to be covered (given names and ages)
Name Age 
Name Age 
Name Age 
Name Age 
Postal Address
Contact Phone Number (hm)(wk)
  (mob)(email)
I am interested in finding out more about the following Benefits:
 TotalCare Life,
     Sum Assured Option 1: $ Option 2: $
 TotalCare Disability Income Protection,
     Sum Assured Option 1: $ Option 2: $
  MajorCare Health, Excess Options: Nil  $300  $600  $1200
Privacy Act Information
This card collects personal information about you. This information is collected by Generation Insurance for the purposes of providing you with the information you have requested. The information collected will be held at Generation Insurance, N/301 Botany Road, Botany, Auckland and PO Box 38813, Howick, Auckland. The Privacy Act 1993 provides certain rights of access to and correction of personal information.