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Contact me about Insurance

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First and Last Name*
Date of Birth (DD-MM-YY)*
Male / Female*
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- Female
Smoker*
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Email Address*
Contact Number*
Mobile Number*
City*
Occupation*
Annual Income/Salary*
Monthly Mortgage Payment
Mortgage Outstanding
Employed*
- Employed
- Self Employed
I would like someone to contact me about
- Life Insurance
- Monthly Life Insurance
- Fixed Price / Long Term Life Insurance
- Trauma / Critical Illness Insurance
- Kids Trauma Insurance
- Cancer Insurance
- Income Protection / Temporary Disablement
- Mortgage Protection Insurance
- Redundancy Insurance
- Permanent Disablement Cover
- Health Insurance
Best time to call me*
Terms and Conditions and Privacy Policy*
I/We have read, understood, and accept the privacy policy. I/We agree that Ease Insurance can provide services, information and advice to us relating to insurance. I/We authorise the collection and holding of our information, and disclosure of our details to any third parties that provide an operational service to Ease Insurance.

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Head Office:
Building 730, Level 3, 261 Morrin Road, St Johns, Auckland 1072

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