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Online Quote
Needs Analysis Online Quote #2
Needs Analysis
Please enable JavaScript in your browser to complete this form.
1.) Name and Surname
*
First
Last
2.) ID No
*
3.) Residential Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
4.) Tel
5.) Cell
*
6.) Email Address
*
7.) What is your occupation?
*
8.) Are you part of your employer’s group scheme?
*
Please select
Yes
No
9.) Indicate how many members should be quoted for:
*
1
2
3
4
5
Please mention: Name and Date of Birth below
Name_1
*
First
Last
Nam_2
*
First
Last
Name_3
*
First
Last
Name_4
*
First
Last
Name_5
*
First
Last
If any of your children is over the age of 21, please mention if they are studying or in employment?
10.) Are you currently on a Medical scheme?
*
Yes
No
If YES, please mention scheme and option and starting date:
(This information should be as complete and accurate as possible to determine waiting periods and late joiner penalties)
If NO, please indicate when last you had membership on a scheme:
(This information should be as complete and accurate as possible to determine waiting periods and late joiner penalties)
11.) What problems / challenges do you have with your current scheme?
*
12.) Does anyone seeking membership have any chronic conditions?
*
Yes
No
If Yes, please name condition:
*
If Yes, please name medication:
*
13.) Does anyone have Specified medical conditions that needs to be attended to?
*
(Pregnancy / Back or Neck Problems / planned operation/ Joint replacements / cancer)
14.) Does anyone require Spectacles?
Yes
No
15.) Does anyone require specialised Dentistry?
Yes
No
16.) Has anyone been admitted to hospital in the last 12 months?
*
Yes
No
If Yes, please give detail:
17.) What is your Income per month?
*
(As some products are income based)
18.) Do you want cover for your day-to-day expenses?
*
Yes
No
(e.g. doctors, specialist, dentists and medicines)
19.) Would you be willing to use network of service providers?
*
Yes
No
(Hospitals, doctors and specialists)
20.) Which hospital is your preferred hospital in your area?
*
21.) What is your monthly budget for a medical aid premium?
*
(please do answer this as this will give me an indication of what I can quote on)
22.) Would you like more information on GAP and Co-Payment cover?
*
Yes
No
23.) What other schemes would you want to receive information about?
*
24.) Where did you hear of my services?
*
Submit
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