Needs AnalysisPlease enable JavaScript in your browser to complete this form.1.) Name and Surname *FirstLast2.) ID No *3.) Residential Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeLayout4.) Tel5.) Cell *6.) Email Address *7.) What is your occupation? *8.) Are you part of your employer’s group scheme? *Please selectYesNo9.) Indicate how many members should be quoted for: *12345Please mention: Name and Date of Birth belowName_1 *FirstLastNam_2 *FirstLastName_3 *FirstLastName_4 *FirstLastName_5 *FirstLastIf 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? *YesNoIf 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? *YesNoIf 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?YesNo15.) Does anyone require specialised Dentistry?YesNo16.) Has anyone been admitted to hospital in the last 12 months? *YesNoIf 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? *YesNo(e.g. doctors, specialist, dentists and medicines)19.) Would you be willing to use network of service providers? *YesNo(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? *YesNo23.) What other schemes would you want to receive information about? ***For the following services, I use trusted referral partners who are experts in their fields– If you click yes on the following questions, your contact details will be shared with the relevant partners to contact you.24.) Can I review the following products for your short-term insurance (Car and household) *YesNo25.) Can I review your Life and Retirement Annuity policies? *YesNo26.) Do you need to review your Will? *YesNo27.) Do you have a need for a tax consultant? *YesNo28.) Where did you hear of my services? *Submit Disclosure Notice
