Experience NZ Insurance
Apply Online
Please complete the form below in English
Step 1 – Applicant Details
Family Name *
First or Given Name *
Date of Birth *
Gender*
Country of origin *
Phone Number *
Email Address *
Confirm Email Address *
Agent Email Address (optional)
Type of Visa *
Are you new OrbitProtect policy holder? *
How did you hear about us? *
Please complete the form below in English
Step 2 – Other applicant details
Fill in the details of other applicants included in this application.
Spouse
Family Name
First or Given Name
Date of Birth
Gender
Dependants
Number of dependants to include in this policy
Dependant 1
Family Name
First or Given Name
Date of Birth
Gender
Dependant 2
Family Name
First or Given Name
Date of Birth
Gender
Dependant 3
Family Name
First or Given Name
Date of Birth
Gender
Dependant 4
Family Name
First or Given Name
Date of Birth
Gender
Dependant 5
Family Name
First or Given Name
Date of Birth
Gender
Dependant 6
Family Name
First or Given Name
Date of Birth
Gender
Please complete the form below in English
Step 3 – Cover Options
Make a selection below
Not sure which option you want? The Experience NZ Brochure explains the difference between Lite and Prime.
Specified items cover
Check this box if you want to specify items to be insured.
You have indicated you would like to specify items to be insured, our customer service officers will contact you to discuss with you the item(s) you can insure. Please note, additional premiums apply for this special cover.
Experience NZ Prime AUTOMATICALLY covers property up to NZ$10,000. Experience NZ Lite does not provide automatic property cover. Alternatively, you can choose to specify the items you want to insure.
Additional Options
Manual Work Cover for dairy farming, building and related trades cover
Not selected
Manual Work Cover for dairy farming, building and related trades cover
Add 20% of the individual Experience NZ Lite premium to the cover period.
Additional information
Do you have any pre-existing medical conditions?
A pre-existing condition is any medical or physical condition or circumstance that you are aware of, or ought to be aware of, that you have before the start date of the insurance. Remember: any existing condition (Asthma, Acne as examples) that may not have been active prior to the insurance start date that reoccurs after the start date will NOT be covered.
Declaration confirmed
I agree to be bound by the OrbitProtect Experience NZ insurance Policy Wording (Lite or Prime as selected) and the Terms of Sale.
Please complete the form below in English
Step 3a – Medical conditions: Additional information
4. Have you ever received treatment for any type of:
Additional information
Please describe your medical condition:
What medication or treatment has been prescribed to treat your medical condition?
What is your doctor's name?
What date did you last visit your doctor?
What is your doctor's address?
Please note: There is a non-refundable one-off fee of $45.00 NZD for the assessment irrespective of the outcome.
Your application for Experience NZ Insurance
Policy Summary
Total Premium
$ NZD
Insured
Spouse
Children
Country of origin
Phone
Start date
End Date
Medical Conditions Warning
Medical Conditions Assessment Fee
$45.00 NZD
Your pre-exisiting medical conditions are not automatically covered under the Policy. Your application will be referred to our OrbitProtect team for assessment. Our Customer Service Officer will contact you. You will be notified in writing of the outcome of the assessment.
Underwriting Review
You are currently under underwriting review. Your application will be referred to our OrbitProtect team. Our Customer Service Officer will contact you. You will be notified in writing of the outcome of the assessment.
Please note that you are not insured until the premium has been paid in full.
High value items
You have indicated you would like to specify items to be insured, our customer service officers will contact you to discuss with you the item(s) you can insure. Please note, additional premiums apply for this special cover.
Select Payment Method
Offline Payment via NZ Bank Transfer
An invoice with payment instructions will be sent to your email address
Offline Payment Warning
In order to make payment into our bank account in New Zealand:
- You MUST have a New Zealand bank account if you are making payment through the internet.
- You MUST be able to go to a Westpac Bank in New Zealand to deposit cash in to our bank account.
Offline Payment
Reference Number
Invoice and Payment instructions
An invoice with payment instructions has been sent to your email address.
View invoice
Credit Card Payment
Reference Number
You may now proceed with your online payment.
