Life Insurance Questionnaire – The Financial Fitbit Consultancy Ltd

Name *

First

Last

Email *

Phone Number *

Gender *

Female
Male

Date of Birth *

What is your estimated annual income? *

As a guideline, an adequate Whole Life Insurance cover is typically 10× your annual income (Sum Assured). This helps us prepare two personalized quotes: one based on your preferred monthly premium and another based on the recommended Sum Assured.

What is your desired monthly premium budget ? *

This is the amount you are comfortable in paying depending on your personal evaluation of your income and expense level for a period of 10, 15 or 20 years.

My income is: *

Regular (I have a salary, business has consistent income etc)
Irregular (I am in freelancing, starting out in business, between jobs etc)
Other

What is your smoking status? *

Smoker (cigarette, e-cigarette, vape, any tobacco use)
Non smoker

Premium Payment Term *

10 years
15 years
20 years

This is a Whole Life Insurance policy, your cover lasts for your entire lifetime, even after you have completed your premium payments. The death benefit (Sum Assured) is paid to your beneficiaries upon your passing.

What is your overall knowledge of life insurance? *

Really good
Somewhere in the middle
No knowledge at all

Do you have any form of life cover? *

Yes, Group Life (through work)
Yes, Personal Life
No

Are there any additional protection benefits you would like included in your Whole Life Insurance cover?

Critical Illness Cover
Total & Permanent Disability (TPD) Cover

Critical Illness Cover: Protects you financially if you're diagnosed with a serious illness — such as cancer, heart attack, stroke, kidney failure, or paralysis — before age 65. On diagnosis, the underwriter pays you a lump sum (the Critical Illness sum assured) as discretionary money, meaning you can use it however you need — medical bills, treatment abroad, income replacement, or daily expenses — while your life cover continues. Total and Permanent Disability (TPD) Cover: Protects you if an accident leaves you permanently unable to work or care for yourself (e.g. loss of limbs, sight, or inability to perform basic daily activities). The underwriter pays out a lump sum benefit as discretionary money to help cushion the financial impact, while the rest of your policy stays active.

What AMOUNT of critical illness cover do you want to receive?

The listed critical illnesses are: Accidental brain damage, Alzheimer's disease, Aorta surgery, blindness, cancer, coma, coronary artery surgery, heart attack, major organ transplant, motor neuron disease, multiple sclerosis, muscular dystrophy, paraplegia/ paralysis, Parkinson's disease, renal failure, replacement of heart valve, rheumatoid arthritis before the age of 60 and stroke. Premium payment for critical illness will stop at the earlier of the premium payment term or the attainment of age 65

What AMOUNT of Total & Permanent Disability (TPD) Cover do you want to receive?

Provides additional protection in the event of death or total and permanent disability caused by an accident Available to applicants aged 15–59 years .Additional sum assured: between KES 1 million and KES 20 million, capped at 100% of the main policy sum assured Payable for accidental death or TPD occurring before age 65

Any additional information