Insurance Fact Find

Thank you for taking the time to complete our insurance fact find and allowing us to get to know you.

The information we collect enables us to provide you with bespoke personal insurance options. When dealing with your personal information, Blueprint Protect complies with the New Zealand Privacy Act 2020.

The form will take 15–20 minutes to complete.

Review our Privacy Policy → Review our Public Disclosure Statement →

Step 2

People

Please tell us who this insurance review is for.

This review is for: *

Just myself Myself and my partner

Do you have any dependent children? *

Yes No

Step 3

Goals

We can give you advice but our process works better when we understand what you want to achieve. You call the shots.

What would you like to achieve from this insurance review?

Are any of the following important to you?

Protecting my income Protecting my family Access to the best private health treatment Reviewing / saving money on my existing cover Finding the right cover to fit my budget Understanding who the best insurer is for my particular needs Understanding what benefits are available and the best structure Peace of mind / protecting against the unexpected Paying off debt

Step 4

Your Personal Details

Please complete your personal details below.

Title *

Preferred Name

First Name *

Last Name *

Date of Birth *

Format: DD-MM-YYYY

Gender *

Relationship Status *

Residency Status *

Best Email *

Mobile Phone Number *

Employment Status *

Step 5

Partner's Personal Details

Please complete your partner's personal details below.

Title *

Preferred Name

First Name *

Last Name *

Date of Birth *

Format: DD-MM-YYYY

Gender *

Relationship Status *

Residency Status *

Best Email *

Mobile Phone Number *

Employment Status *

Step 6

Dependants

Understanding your family situation helps us ensure nothing important is missed.

Child 1

First Name

Last Name

Date of Birth

Gender

Step 7

Your Income

Please tell us about your income from your main occupation. There is another section for other income.

Occupation / Full Job Title *

Industry of Work *

How often are you paid? *

Average Hours Worked Per Week *

Income Before Tax *

$

Do you have a Student Loan? *

Yes No

Notes about your income or occupation

Step 8

Partner's Income

Please tell us about your partner's income from their main occupation.

Occupation / Full Job Title *

Industry of Work *

How often are they paid? *

Average Hours Worked Per Week *

Income Before Tax *

$

Do they have a Student Loan? *

Yes No

Notes about your partner's income or occupation

Step 9

Other Income

This section is for other income that has not already been noted.

Do you have any other income relevant to this review? *

Yes No

Notes regarding other income

Step 10

Living Situation

Please let us know your current living arrangements.

What is your living situation? *

Home Address *

Street Address

Address Line 2

City

Postal / Zip Code

Step 11

Property & Mortgages

Please tell us about any property you own and any mortgages.

Do you own any property? *

Yes No

Notes regarding property & mortgages

Step 12

Essential Expenses

These are costs that must continue even if you had a sudden change in income.

Include: Rent, Food, Power & Gas, Insurances, Rates, Vehicle Costs, Childcare, Phone & Internet

Don't include: Mortgage repayments or discretionary spending (entertainment, subscriptions, eating out)

Total Essential Expenses *

$

Frequency *

Step 13

Your KiwiSaver

KiwiSaver balances can reduce the level of life cover required. We also have an in-house KiwiSaver adviser who may be able to help.

Do you have KiwiSaver? *

Yes No

Are you regularly contributing to KiwiSaver? *

Yes No — irregularly No — not at all

What is your contribution rate? *

KiwiSaver Balance (approximately)

$

KiwiSaver Fund Provider

Step 14

Partner's KiwiSaver

Please tell us about your partner's KiwiSaver.

Does your partner have KiwiSaver? *

Yes No

Is your partner regularly contributing to KiwiSaver? *

Yes No — irregularly No — not at all

What is your partner's contribution rate? *

Partner's KiwiSaver Balance (approximately)

$

Partner's KiwiSaver Fund Provider

Step 15

Assets

Please provide approximate values. These help us understand your overall financial position. All fields are optional.

Cash Savings / Bank Deposits

$

Shares / Managed Funds

$

Term Deposits

$

Other Investments (Cryptocurrency, Gold, Silver, etc.)

$

Step 16

Liabilities

Please tell us about any other major liabilities you may have (excluding mortgages already noted).

Liability 1

Type

Outstanding Balance

$

Step 17

Existing Insurance

As part of our review we will consider any existing cover you have in place.

Personal insurance includes: Private Medical Cover, Income or Mortgage Protection, Trauma or Critical Conditions Cover, Permanent Disability or TPD Cover, and Life Insurance.

Do you have any existing personal insurance? *

Yes No

Notes regarding existing cover

Upload a copy of your existing policy schedule

If you have copies readily available you can upload them here, or we can gather them at a later date. Optional.

Almost done!

Thank you for completing your Insurance Fact Find. Hit Submit below and we'll be in touch shortly.

By submitting this form you confirm that the information provided is accurate to the best of your knowledge. This information will be held in accordance with the New Zealand Privacy Act 2020.

Insurance Fact Find

People

Goals

Your Personal Details

Partner's Personal Details

Dependants

Your Income

Partner's Income

Other Income

Living Situation

Property & Mortgages

Essential Expenses

Your KiwiSaver

Partner's KiwiSaver

Assets

Liabilities

Existing Insurance

Health & Lifestyle

Your Details

Partner's Details

Nature & Scope

Cover important to you

Cover important to your partner

Almost done!