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  • Services
    • Services OverviewHelp with all aspects of lending and insurance
    • Second Column
      • Business InsuranceMore cover for less premium
      • Shareholder Protection & Buyout InsuranceBuyout Insurance
      • Franchise Brand ProtectionReduce damage to your brand
      • Home FinanceGetting people into homes
    • Third Column
      • KiwisaverSave for your retirement
      • Fire & GeneralGreat premiums
      • Life & IncomePeace of mind
      • Mortgage & Household ExpensesPerfect combined with Income Cover
      • Medical & TraumaMedical care that suits you
  • About Us
  • Our People
  • Testimonials
  • Contact
  • Needs Analysis Form

    Peak Financial Services Needs Analysis Form

    Step 1 of 6

    16%
    Instead of completing paper-based and sometimes complicated application forms, Peak Financial Services brings you an easy to complete, online Needs Analysis form.
    Please complete as much information as possible to avoid unnecessary delays. Some fields are mandatory.

    Personal Information

    Name(Required)
    Address
    Physical
    Postal Address
    If different to your physical address
    Date of birth(Required)
    Do you smoke(Required)
    In the last 12 months

    Applicant 2 | Personal Information

    Applicant 2 Name(Required)
    Is Your Address The Same As Applicant 1(Required)
    Applicant 2 Address
    Physical
    Applicant 2 Date of birth(Required)
    Applicant 2 Do you smoke(Required)
    In the last 12 months

    Citizenship & Visa

    Are You a NZ Citizen(Required)
    Are you a Permanent Resident(Required)
    Do you have a visitor Visa or work Visa(Required)
    Is your Visa more than 2 years(Required)
    Do you have at least 6 months left before your Visa expires(Required)

    Authorities

    Authority to enquire signed?
    Authority to act as broker signed?

    Children / Dependants


    Do you have dependents(Required)
    Detail if they are living at a different address
    Purpose of Interview

    Assets and Liabilities

    Assets
    Bank/type and $Value
    Bank/type and $Value

    Vehicle 1

    Vehicle 2

    Vehicle 3

    Please list and include the dollar value
    Please list and include the dollar value
    Please list and include the dollar value
    Please list and include the dollar value

    Liabilities

    Mortgage
    Personal Loan
    Credit Card(s)

    Life Cover Needs

    In the event of you passing away what would you want to happen?
    e.g. funeral expenses
    (see liabilities)
    [1] amount to replace [2] number of years to replace [3] expected rate of return
    e.g. children’s education expenses
    (Individual; Joint; Trust; Business)

    TPD Needs

    In the event you were Totally & Permanently disabled what would you want to happen?
    e.g. funeral expenses
    (see liabilities)
    [1] amount to replace [2] number of years to replace [3] expected rate of return
    e.g. children’s education expenses
    (Individual; Joint; Trust; Business)

    Trauma Needs

    If you were to experience, or be diagnosed with, a major trauma what would you want to happen?
    e.g. funeral expenses
    (see liabilities)
    [1] amount to replace [2] number of years to replace [3] expected rate of return
    e.g. children’s education expenses
    (Individual; Joint; Trust; Business)

    Income Protection Needs

    How long could you cope financially if you were unable to work?
    e.g. funeral expenses
    (see liabilities)
    [1] amount to replace [2] number of years to replace [3] expected rate of return
    e.g. children’s education expenses
    (Individual; Joint; Trust; Business)
    Income cover waiting period
    How long do you want to wait from the time you make your income protection claim, to the time where your insurance company starts making regular payments to you
    Income payment term duration
    What length of time would you like to be covered for

    Mortgage Protection Needs

    How long could you cope financially if you were unable to work?
    Mortgage cover waiting period
    How long do you want to wait from the time you make your mortgage protection claim, to the time where your insurance company starts covering regular payments for you
    Mortgage cover term duration
    What length of time would you like your mortgage to be covered for

    Medical Insurance

    Existing Cover
    Hospital / Major Medical Cover Need
    Hospital / Major Medical Cover Do Not Need
    Existing Cover
    Specialists & Tests Need
    Specialists & Tests Do Not Need
    Existing Cover
    GP / Prescription Cover Need
    GP / Prescription Cover Do Not Need
    Existing Cover
    Dental and Optical Cover Need
    Dental and Optical Cover Do Not Need
    Existing Cover
    Future Insurability Need
    Future Insurability Need

    History

    e.g operations, hospitalizations, abnormal blood test result before like elevated blood sugar or gestational diabetes, breast lumps, PCOS, endometriosis, heavy bleeding, dysmenorrhea, migraine
    Have you been admitted to hospital in the last 5 years?
    Have you seen a doctor for anxiety, stress or depression?
    e.g. back, neck, knees, pain, sprain, fracture, curvature problems (scoliosis, thoracic or not?) etc
    e.g. Cancer, stroke, heart attack, diabetes, polycystic kidney disease, cardiomyopathy, any hereditary condition such as thalassemia etc
    Do you participate in any dangerous sports / pastimes?

    Current Insurers

    Existing Life Cover
    Life Provider
    Life Commenced
    Existing Trauma Cover
    Trauma Provider
    Trauma Commenced
    Existing TPD Cover
    TPD Cover
    TPD Commenced
    Existing Income Cover
    Income Provider
    Income Commenced
    Existing Mortgage Cover
    Mortgage Provider
    Mortgage Commenced
    Existing Medical Cover
    Medical Provider
    Medical Commenced

    If changing insurers, a change in health since your last application can have an impact on your insurance policy:

    • The need to disclose all relevant information requested on the application form as failure to do so or making incorrect statements may result in future claims being declined.
    • If your health has changed since taking out your existing cover then it may mean exclusions or loadings on the new cover. Therefore, we recommend not cancelling the existing cover until the new cover terms have been accepted and are better or in line with your existing insurance.

    Kiwisaver

    weekly/fortnightly/mthly (specify timeframe)
    weekly/fortnightly/mthly (specify timeframe)

    Estate Details

    Do you have a will

    Goals

    Thinking about the summarised events outlined below, what would you consider and evaluate as being the main priorities that you would like to discuss?

    Various risk cover options

    Protection in the event of a premature Death or a Terminal illness
    Protection of your Income
    Short Term Serious injury or illness protection
    Long term disability due to a serious injury or illness (own occupation cover)
    Mortgage repayment cover including specific injury & illness cover with no wait period
    Household expenses cover for rent, Sky TV, Internet, HP’S including specific injury cover
    Private medical cover for elective surgery, hospital & non hospital care & diagnostic tests
    This can cover, any immediate goals, 5-year goals, life goals.
    When you successfully submit your form, this person will receive your Needs Analysis information. A copy will also be sent to your email address.
    Client Declaration(Required)
    Terms of Service
    I / We understand that the information in this form is used to make recommendations regarding my / our personal risk management, medical insurance, retirement planning, investment, mortgage finance and fire & general insurance needs.
    I/We confirm that our named adviser has given us clear and concise information regarding the possible dangers of transferring cover from one company to another.
    I / We declare that the information provided by me / us to the named adviser is to the best of my / our knowledge accurate:
    i/ We authorise Peak Financial Services Limited and their advisers to act on our behalf in all matters related to our insurances, Mortgage and other finance and Kiwisaver and to release information to third parties to facilitate this.
    I/WE confirm that we have read and understood the terms and conditions on the Peak Financial website
    Agreement(Required)
    You must agree to the terms before you can submit this form.

    Peak Financial Services

    Contact Us

    +64 (0)21 949772
    gary@peakfinancial.co.nz

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    16 Moiri Pl, Maungatapu,
    Tauranga

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