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Fluent lead gen
1
Name
Phone
Email
Occupation
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2
Date of birth
*
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/
Day
Month
Year
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3
What coverage are you most interested in?
*
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Income Protection
Health Insurance
Life Insurance
Trauma Cover
All of the above
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4
Who do you need protection for?
*
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Just me
Me & my partner
My whole family
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5
Do you currently have a policy?
*
This field is required.
Yes. Reviewing it
No. Starting fresh
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6
What fortnightly premium fits your budget?
*
This field is required.
Under $50
$50–$100
$100–$150
$150-$200
$200+
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7
How would you describe your current health?
*
This field is required.
Excellent
Good
Managed health condition
Prefer to discuss with advisor
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8
When would you need your Cover to kick in?
*
This field is required.
As soon as possible
This month
Next 3 months
Not sure yet
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9
How do you prefer to connect?
*
This field is required.
Phone call
Video call
In person
Email first
Text to arrange
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10
How many financial dependants do you have?
*
This field is required.
None
1–2
3–4
5 or more
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11
Are you ready to receive your personalised conversation?
*
This field is required.
Yes, call me now
Yes, email me
Urgent, I need cover ASAP
Just exploring for now
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12
What is your residency status?
*
This field is required.
I'm a citizen
I have a resident visa
I have a work visa
I'm travelling
Other
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