Advice Warning
The advice to be provided to you by answering the questions below will be based on a limited set of information. Because of that you should, before acting on the advice, consider the appropriateness of the advice having regard to your relevant personal circumstances.
If you require a more comprehensive risk plan then please arrange for an interview by contacting Pilot Cover on:

Phone: 07 3849 0767
Freecall: 1800 20 23 20

Further if you presently have income protection then please provided details of this cover in the 'Additional Information/Questions' box.

Step 1.Please complete

Do you require for yourself:

INCOME PROTECTION
TERM LIFE COVER
CRITICAL ILLNESS COVER

Do you require cover for your spouse/partner:

TERM LIFE COVER
CRITICAL ILLNESS COVER

Have you noted the contents of the financial services guide?

Yes

My details are: (all fields are required)

Full Name:

Date Of Birth (dd/mm/yy):

Gender: Male Female

  Contact Telephone:

  Email Address:

Fax Number:

Address:

State:

Postcode:

Country:

Employer (Airline)

Type of Flights
(eg. Domestic)

No. of years as a commercial pilot

Annual Salary $AUD

Monthly Benefit required:

Do you smoke? Yes No

Wait period for Income Protection (days) 90 180
360 730

Premium Basis Stepped Level

Term Life Required
$500,000 $750,000
$1,000,000

Critical Illness Required $250,000 $500,000
$750,000 $1,000,000

Step 2   (optional.)

Prefered contact method: Telephone Email Post

How did you hear about us?

Additional Comments:

Do you require cover for your spouse/partner? Yes No

My Spouse/Partners details: (if applicable)

Additional Comments: