Financial Hardship Application

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Reference (Policy number/Claim number/Other reference)

Applicant 1 First Name *

Applicant 1 Last Name *

Applicant 2 First Name

Applicant 2 Last Name

If there are more than two applicants, please add details in the comments field.

CONTACT DETAILS

Street address

Address Line 2

City

State

Postcode

Country

Preferred contact number *

Email address *

We will use this email address for all written communication unless you advise us that you want to receive contact by post.

DEPENDANTS

Dependent 1 full name and age

Dependent 2 full name and age

Dependent 3 full name and age

Dependent 4 full name and age

If there are more than four dependants, please add details in the comments field.

HARDSHIP DETAILS

Please explain the reason for your application.

NATURE OF ASSISTANCE

What assistance would you like IIS to consider?
– Extension of due date for payment. If so, when will you be able to make payment?
– Paying in instalments. What can you afford, how often and over which period?
– Paying a reduced lump sum. What can you afford?
– Postponing one or more instalments. When will you be able to start/re-start making payment?
– Other (including a combination of the above options or a possible waiver of the debt).

Please provide details of what you are seeking.

ANY FURTHER COMMENTS OR DETAILS

If you have any questions about the process, or if you require assistance to complete this application, please contact us.