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

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

Any additional information