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Please complete this form. If you have any questions message

AJ - 0221304950

or email - aj.aledron@cfan.co.nz

Birthday
Day
Month
Year
Smoking Status
YES
NO
Residency Status
Citizen
PR
Resident
Working Visa
Marital Status
Married
Defacto
Widowed
Separated
Single
Do you have a mortgage?
YES
NO

Full disclosure means sharing all health and lifestyle details truthfully. Without it, your policy or claim may be denied. Honesty ensures you receive proper cover and support when needed.


example:

*Fractured shoulder was not able to work for 3 months - 2020 January.

*Diagnosed with Diabetes 2019 Feb - Taking Metformin 5mg 1 tab once daily

example:

Mom - hypertensive, Diabetic diagnosed when she was above 50

Dad - Cancer died at 52 years old

Your bank account number is needed to process your application, but no money will be deducted until you approve the final offer. The first month is free—your first payment will be deducted one month after your cover starts.

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BrainChamp Inc. 2025

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