Please complete all questions below then click the Submit This form will be emailed to Routherbury Insurance, for the purpose of providing a Quote for health Insurance with Southern Cross. Contact Details Name * Email Address * Phone Number * Applicants DetailsPlease complete all details for the additional applicantsApplicant Title * First name * Surname * Date of Birth * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Please Select * Female Male Health Questions Are you a non-smoker?† †Have not smoked at all over the past 12 months. * - Select -YesNO Do you eat at least 5 servings of fruit and vegetables a day? * - Select -YesNo FEMALE: Do you drink 2 or less glassesof alcohol a day (14 per week)? - None -YesNo MALE: Do you drink 3 or less glassesof alcohol a day (21 per week)? - None -YesNo Spouse/ partner DetailsApplicant Spouse / Partner Title First name Surname Date of Birth Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Please Select Female Male Health Questions Are you a non-smoker?† †Have not smoked at all over the past 12 months. - None -YesNO Do you eat at least 5 servings of fruit and vegetables a day? - None -YesNo FEMALE: Do you drink 2 or less glassesof alcohol a day (14 per week)? - None -YesNo MALE: Do you drink 3 or less glassesof alcohol a day (21 per week)? - None -YesNo Other Dependent 18 years or Older Details 1Applicant other dependents 1 Title First name Surname Date of Birth Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Please Select Female Male Health Questions Are you a non-smoker?† †Have not smoked at all over the past 12 months. - None -YesNO Do you eat at least 5 servings of fruit and vegetables a day? - None -YesNo FEMALE: Do you drink 2 or less glassesof alcohol a day (14 per week)? - None -YesNo MALE: Do you drink 3 or less glassesof alcohol a day (21 per week)? Yes No Other Dependent 18 years or Older Details 2Applicant other dependents 2 Title First name Surname Date of Birth Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year1948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Please Select Female Male Health Questions Are you a non-smoker?† †Have not smoked at all over the past 12 months. - None -YesNO Do you eat at least 5 servings of fruit and vegetables a day? - None -YesNo FEMALE: Do you drink 2 or less glassesof alcohol a day (14 per week)? - None -YesNo MALE: Do you drink 3 or less glassesof alcohol a day (21 per week)? - None -YesNo
