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) *In case of death (natural or accidental the underwriter will pay immediately 100% he sum assured to the listed beneficiaries.What is your monthly budget for your life cover (the MONTHLY premium you want to pay)? *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 or 15 years.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. The waiting period will be waived upon confirmation of good health, following assessment of the submitted medical report and the outcome of the underwriting decision Premium payment for critical illness will stop at the earlier of the premium payment term or the attainment of age 65What is your preferred mode of communication? *EmailPhone callWhatsapp/MessageAny of the aboveOtherAny additional informationSubmit