Person 1

Full Name*

Date of Birth*

Number and Age of Dependents*

Birth Country*

Citizen / Permanent Residency

Address*

Same as mailing address

Address before your current address*

Phone*

Email*

Person 2

Full Name*

Date of Birth*

Number and Age of Dependents*

Birth Country*

Citizen / Permanent Residency

Address*

Same as mailing address

Address before your current address*

Phone*

Email*

Person 3

Full Name*

Date of Birth*

Number and Age of Dependents*

Birth Country*

Citizen / Permanent Residency

Address*

Same as mailing address

Address before your current address*

Phone*

Email*

Person 1's Income Details

Occupation*

Employer / Business Name*

Previous Income Details*

Person 2's Income Details

Occupation*

Employer / Business Name*

Previous Income Details*

Person 3's Income Details

Occupation*

Employer / Business Name*

Previous Income Details*

Financial Details

Main Bank & Branch*

Money at Bank/Other

Property

Vehicle

Superannuation

Life Insurance

Business Value (Net)

Boat / Caravan

Furniture & Personal Effects

Overdraft

$
$

Mortgage

$
$

Personal Loans

$
$

Credit / Store / Charge Cards

$
$ $

Other Liabilities (including fines, IRD debt, Ministry of Justice, etc)

$
$

Child Support Paid

Fixed Monthly Costs

School Fees*

Tithing*

Pay TV/Sky/Netflix*

Gym Membership*

Other*

Other Incomes

Rental Income

Other Income (Boarder Income, Working for Families, IRD, etc)

Would you like us to arrange for an insurance adviser to be in touch regarding the cover you require with your mortgage?

Other notes in support of application: