Life Insurance

1. Your Details
Title:
  • Mr.
  • Mrs.
  • Miss
  • Dr.
  • Prof.
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This question is required.
Name:
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Surname
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ID Number:
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Phone Number:
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Email Address:
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2. What is your aim in reviewing your life insurance?
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3. Can we send you a digital link that gives us consent to view the insurance policies you currently have? (The link will come as an SMS from a website called Astute which allows us to view only, not make any changes.)
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3.1 Please tell us how much cover you have.
For life cover:
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For disability cover (lump sum):
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For disability cover (monthly income protection):
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For dread disease:
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4. How is your health?
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5. We need some details about you in order to run insurance quotes, can you please tell us:
5.1. Are you married?
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5.2. How are you married?
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5.3. Do you smoke?
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5.4. What is your occupation?
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5.5. What is your salary (after tax)?
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5.6. What is your highest qualification?
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6. Would you like us to work out how much cover you need?
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6.1. What is your affordability for cover?
For Life Cover:
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For Disability Cover:
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For Dread Disease Cover:
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Total
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Life Cover Needs

7. How much outstanding debt do you have?

Debt:

Amount owing
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Years left to pay:
-
+
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Field is required!

Debt:

Amount owing
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Field is required!
Years left to pay:
-
+
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Field is required!

Debt:

Amount owing
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Field is required!
Years left to pay:
-
+
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Field is required!
8. Who do you support? These are people that you need to provide money for if you pass away

Dependant:

Name
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Relationship
  • - select a option -
  • Child
  • Spouse
  • Parent
  • Other
- select a option -
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Field is required!
Monthly amount they will need if you pass away
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Field is required!
Their current age:
-
+
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Field is required!
At what age should the monthly amount stop:
-
+
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Field is required!

Dependant:

Name
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Field is required!
Relationship
  • - select a option -
  • Child
  • Spouse
  • Parent
  • Other
- select a option -
Field is required!
Field is required!
Monthly amount they will need if you pass away
Field is required!
Field is required!
Their current age:
-
+
Field is required!
Field is required!
At what age should the monthly amount stop:
-
+
Field is required!
Field is required!

Dependant:

Name
Field is required!
Field is required!
Relationship
  • - select a option -
  • Child
  • Spouse
  • Parent
  • Other
- select a option -
Field is required!
Field is required!
Monthly amount they will need if you pass away
Field is required!
Field is required!
Their current age:
-
+
Field is required!
Field is required!
At what age should the monthly amount stop:
-
+
Field is required!
Field is required!
9. Are you leaving everything you own to your spouse if you pass away? (We ask this because if you are, the expenses on your estate are much lower)
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9.1. What is the total value of everything you own in your name?
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9.2. What % of everything you own are you NOT leaving to your spouse?
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Field is required!

Disability Needs

If you are no longer able to work, what monthly income will you need to sustain you and your family?
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Submit