Life Insurance Questionnaire Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number *Gender *FemaleMaleDate of Birth *What is your estimated annual income? *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)OtherMarital status: *SingleMarriedDomestic PartnershipDivorcedWidowedWhat is your smoking status? *Smoker (cigarette, e-cigarette, vape, any tobacco use)Non smokerWhat is your overall knowledge of life insurance? *Really goodSomewhere in the middleNo knowledge at allWhy is it important to get your life cover today? *To protect my family and income against unforeseen serious illness, death, disability onlyTo protect my family as above and leave an inheritanceOtherDo you have any form of life cover? *Yes, Group Life (through work)Yes, Personal LifeNoWhat level of protection are you looking for (The sum assured) Or what is your monthly budget for your life cover (the premium you want to pay)? *What is your preferred mode of communication? *EmailPhone callWhatsapp/MessageAny of the aboveOtherAny additional informationSubmit
