SUDAC Life Cover Quote Form

SECTION 1 INSURED LIFE

Your Name and Surname *

Gender *

Male

Female

Relationship Status *

Single

In Relationship

Married

How long have you been in the relationship

Greater than 5 years

Less than 5 years

Your Gross Monthly income: *

Your Gross Household income:

For you and your partner put together.

ID Number *

Passport Number

Are you a permanent South African resident? *

Yes

No

Residential Address *

Apartment, suite, etc.

City

Postal Code

Postal Address *

City

Postal Code

Email *

Mobile Phone *

Alternative Phone

Communication Preference *

Post

E-Mail

SMS

Are you currently insolvent, or are you aware of any processes pending against you for liquidation or administration?

Yes

No

Are you a politically exposed person? *

Yes

No

"A PEP generally presents a higher risk for potential involvement in bribery and corruption by virtue of their position and the influence that they may hold."

Are you also the policy holder? *

Yes

No

"Entity that owns an insurance policy and has the right to exercise all privileges under the contract of insurance, except where restricted by the rights of an assignee"

SECTION 2 POLICY OWNER

Name of the Policy Holder

Identity Number of the Policy Holder *

Passport Number of the Policy Holder

Is the Policy Holder a permanent resident in South Africa?

Yes

No

If the Policy holder is a legal entity or Trust, please give the registration number.

Residential Address of the Policy Holder *

Apartment, suite, etc.

City

Postal Code

Postal Address *

City

Postal Code

Email address for Policy Holder *

Mobile Phone Number of Policy Holder *

Alternative Phone Number for the Policy Holder *

Communication Preference? *

Post

E-Mail

SMS

Contact Person for the legal entity? *

Are you or the contact person a politically exposed person? *

Yes

No

A. OCCUPATION

Your Occupation Name? *

The Industry you work in: *

Type of work you do: *

What kind of work do you do on a typical day?

Your highest Qualification? *

Less than Matric

Matric

3 Year Diploma or 3 Year Degree

4 Year Degree or greater

Are you exposed to any hazards or risk of injury during the course of your daily duties? *

Yes

No

Please tick all that apply *

Biohazards, hazardous chemicals

Working at heights greater than 10mt

Working underground for more than 10 hours/week

Commercial diving/ Working underwater

Working with or in the presence of explosives

Working with or in the presence of dangerous machinery

Other

TELL US WHAT YOU ARE INTERESTED IN

What do you need the cover for? *

Choose one or more from the list below.

Providing for family or someone special

Protecting your living standard

Debt protection

Estate duty shortfall

Choose the Cover you are interested in below.

Death Cover

Yes

Disability Cover

Yes

Dread disease Cover

Yes

Income Protection

Yes

DEATH COVER REQUIREMENTS

How do you want us to quote? *

Give me the premium for the cover amount below (example R1mil)

Give me the highest cover for the premium amount below (example R200pm)

Premium amount you want us to quote for?

Cover amount you want us to quote on?

Premium Pattern *

Level Premium Pattern

5% Premium Pattern

You have 2 options here, you can always pay the exact premium for the cover amount you have, called "Level premium" or you can choose to pay a reduced premium now to help your budget and increased premium in later years, called "5% Premium Pattern"

Cover Amount Increase *

0% Annual Increase

3% Annual Increase

6% Annual Increase

Guarantee *

Fix my premium for 5 years

Don't fix my premium

You have the option to fix your premium for 5 years, or allow us to increase it if necessary based on our risk experience. Fixing your premium for 5 years costs slightly more.

DISABILITY OR FUNCTIONAL IMPAIRMENT COVER REQUIREMENTS

How do you want us to quote? (FI) *

Give me the premium for the cover amount below (example R1mil)

Give me the highest cover for the premium amount below (example R200pm)

Premium amount you want us to quote for? (FI) *

Cover amount you want us to quote on? (FI) *

Premium Pattern (FI) *

You have 2 options here, you can always pay the exact premium for the cover amount you have, called "Level premium" or you can choose to pay a reduced premium now to help your budget and increased premium in later years, called "5% Premium Pattern"

Level Premium Pattern

5% Premium Pattern

Cover Amount Increase (FI) *

You can choose to increase the Cover Amount by 3% or 6% annually, or leave it as it is now. (0%)

0% Annual Increase

3% Annual Increase

6% Annual Increase

Guarantee (FI) *

You have the option to fix your premium for 5 years, or allow us to increase it if necessary based on our risk experience. Fixing your premium for 5 years costs slightly more.

Fix my premium for 5 years

Don't fix my premium

Stand Alone or Accelerated? (FI) *

Choose "Stand Alone" if you want this cover to function independently of your Death Cover. Choose "Accelerated" if you want a cheaper gross premium, but keep in mind that claims against this policy will reduce your Death Cover by the same amount.

Stand Alone

Accelerated

To what age do you need this cover? (FI)

Example Age 65

DREAD DISEASE REQUIREMENT

How do you want us to quote? (CI) *

Give me the premium for the cover amount below (example R1mil)

Give me the highest cover for the premium amount below (example R200pm)

Premium amount you want us to quote for? (CI) *

Cover amount you want us to quote on? (CI) *

Premium Pattern (CI) *

You have 2 options here, you can always pay the exact premium for the cover amount you have, called "Level premium" or you can choose to pay a reduced premium now to help your budget and increased premium in later years, called "5% Premium Pattern"

Level Premium Pattern

5% Premium Pattern

Cover Amount Increase (CI) *

You can choose to increase the Cover Amount by 3% or 6% annually, or leave it as it is now. (0%)

0% Annual Increase

3% Annual Increase

6% Annual Increase

Guarantee (CI) *

You have the option to fix your premium for 5 years, or allow us to increase it if necessary based on our risk experience. Fixing your premium for 5 years costs slightly more.

Fix my premium for 5 years

Don't fix my premium

Stand Alone or Accelerated? (CI) *

Choose "Stand Alone" if you want this cover to function independently of your Death Cover. Choose "Accelerated" if you want a cheaper gross premium, but keep in mind that claims against this policy will reduce your Death Cover by the same amount.

Stand Alone

Accelerated

To what age do you need this cover? (CI)

Example Age 65

INCOME PROTECTION REQUIREMENTS

How do you want us to quote? (IP) *

Give me the premium for the cover amount below (example R1mil)

Give me the highest cover for the premium amount below (example R200pm)

Premium amount you want us to quote for? (IP) *

Cover amount you want us to quote on? (IP) *

Premium Pattern (IP) *

Level Premium Pattern

5% Premium Pattern

You have 2 options here, you can always pay the exact premium for the cover amount you have, called "Level premium" or you can choose to pay a reduced premium now to help your budget and increased premium in later years, called "5% Premium Pattern"

Cover Amount Increase (IP) *

You can choose to increase the Cover Amount by 3% or 6% annually, or leave it as it is now. (0%)

0% Annual Increase

3% Annual Increase

6% Annual Increase

In Claim Cover Amount Increase (IP) *

This is similar to the previous questaion, but relates to the cover increasing while you are getting Income Protection payouts due to a claim.

0% Annual Increase

Noa5% Annual Increase

CPI Annual Increase

Guarantee (IP) *

You have the option to fix your premium for 5 years, or allow us to increase it if necessary based on our risk experience. Fixing your premium for 5 years costs slightly more.

Fix my premium for 5 years

Don't fix my premium

To what age do you need this cover? (IP) *

Example Age 65

Deferred Period (IP) *

This is the time you have to wait after you became unable to earn an income before you can put in a claim.

1 Month

3 Months

6 Months

12 Months

Do you know your HIV status? *

I don't know

I am HIV-

I am HIV+

When were you diagnosed as HIV+

What was your CD4 count at date of diagnoses?

What was the date of your last recorded CD4 count?

What was your latest CD4 count?

What was your last recorded Viral Load result?

What was the date of your last recorded Viral Load test?

Have you suffered from any Aids related diseases in the past? *

Yes

No

How many times per year do you have your CD4 and Viral Load tested?

Do you have a Medial Aid? *

Yes

No

Are you currently taking ARVs? *

Yes

No

When did you start taking ARVs?

Has it ever been necessary to change the type of ARV medication you were on? *

Yes

No

B. FOREIGN TRAVEL

Within the next two years, do you expect to travel outside the country for work or any other purpose? *

Yes

No

Please provide full details

C. AVOCATION

Do you, have you, or do you intend to take part in any of the following activities? *

	Yes	No
Aviation (non-passenger)
Parachuting or Skydiving
Scuba diving
Mountaineering & Abseiling
Motor Sport
Powerboat Racing
Extreme Sports
Any pursuit that could be considered dangerous?

If you selected YES on any of the above, please provide full details.

D. INSURANCE HISTORY

Do you have any existing Insurance? *

Yes

No

Please give the totals that your life will be insured for including this application.

Please indicate Death cover, Critical Illness Cover, Disability and Income protector values

Will this new policy replace any of your existing policies? *

Yes

No

Please give the insurer name, policy number, insured benefit amounts.

Has an insurer ever declined, postpone or withdrawn any of your benefit(s) applied for, or accepted it at an increased premium, or reduced the benefit(s) applied for, or issues a benefit subject to an exclusion clause? *

Yes

No

Please provide names of these insurance company/ies.

Have you ever submitted a claim or received a payout from a life insurer? *

Yes

No

E. HABITS, MEASUREMENTS AND FAMILY HISTORY

Have you smoked in the last 12 months? *

Yes

No

How many do you smoke per day? *

Do you consume any form of alcohol? *

Yes

No

What is the average number of units of alcohol that you consume per week? *

1 unit = 1 bottle of beer, 1 glass of wine or 1 tot of spirits

Have you ever had a drug problem or do you currently use any recreational/illicit drugs? *

Yes

No

Have you ever received medical advice to stop/reduce alcohol intake and/or smoking? *

Yes

No

Please provide full details *

Have you ever been advised to, or participated in a rehabilitation programme for substance abuse? *

Yes

No

What is your height in centimeters? *

What is your weight in kilograms? *

Has your weight changed by more than 10% during the last year? *

Yes

No

By how much has your weight changed in the last year? *

Please tell us what the reason for the weight change is

Has any of your father, mother, brother or sister suffered from any hereditary disorder or major illness under the age of 60, as listed below? *

	Father	Mother	Bother	Sister	More than 1	None
Heart Disease
Raised Cholesterol
Stroke
Cancer of the breast
Cancer of the colon
Cancer other than above
Diabetes
Alzheimers disease
Polycystic kidneys
Huntington's disease
Retinitis Pigmetosa
Other (please indicate)

If Other, please give more info

F. DOCTORS/SPECIALISTS/HEALTHCARE PROVIDER(S)

Please provide the name of your regular doctor/specialist/healthcare provider. *

If you don't have a regular doctor, please provide the details of a doctor whom we may send confidential correspondence to (if required)

Practice name *

Are you a member of a medical aid? *

Yes

No

What is the name of the Medical Aid Scheme? *

G. YOUR MEDICAL HISTORY

Do you, or have you ever suffered from Heart or Circulation problems? *

Yes

No

Do you, or have you ever suffered from Respiratory and/ or Lung problems? *

Yes

No

Do you, or have you ever suffered from Digestive system, gall bladder, pancreas or liver problems? *

Yes

No

Do you, or have you ever suffered from Kidneys, Bladder or Reproductive organ problems? *

Yes

No

Do you, or have you ever suffered from Central Nervous System or Mental Health Problems? *

Yes

No

Do you, or have you ever suffered from Spine, joints, bones,muscles, limbs or skin problems *

Yes

No

Do you, or have you ever suffered from Ear, Nose, Throat and Eye, problems? *

Yes

No

Do you, or have you ever suffered from Diabetes, glandular, blood or hormonal disorders? *

Yes

No

Do you, or have you ever suffered from Any from of malignant cancer, growth or tumour/ removed or existing? *

Yes

No

Do you, or have you ever suffered from any form of benign cancer, growth or tumour/removed or existing *

Yes

No

Have you ever sought medical advice, including from any specialist, or undergone any medical examination in the past 5 years for any condition not already mentioned? *

Yes

No

Do you have any intention of having medical investigations, procedures or check-ups done in the next 6 months for conditions that you have already specified in the preceding questions? *

Yes

No

Please give details of medical condition or problem.

Please include Condition, GP name, are you still on treatment, when last you had symptoms, are you recovered.

Do you have any intention of having medical investigations, procedures or check-ups done in the next 6 months for any other condition or symptoms that you have not told us about?

Yes

No

Please give details of medical condition or problem.

Please include Condition, GP name, are you still on treatment, when last you had symptoms, are you recovered.

H. MEDICAL TESTS

If we need to send you to a clinic for medical tests, which one do you prefer?

Clicks

Dischem

What is the name of the closest clinic to you?

Please give us at least two dates and times that will suite you to go for these tests.

IP

SECTION 4 ADDITIONAL QUESTIONS FOR INCOME PROTECTION BENEFITS

Other than the occupation that you have already mentioned, are you involved in any other income generating occupation?

Yes

No

Do you have any intention of changing your occupation (not your employer) within the next 6 months?

Yes

No

Will you continue to receive an income from any other source if you are unable to work such as from rent received on properties you own, investment returns or shareholdings in other companies?

Yes

No

Do you anticipate or expect your income to decrease within the next 12 months?

Yes

No

Are you aware of any reason which may result in you becoming unemployed within the next 6 months such as resignation, retrenchment or disciplinary action pending against you?

Yes

No

SECTION 5 BENEFICIARY

If you want to nominate beneficiaries for proceeds of a Death Cover policy, please provide Name, Surname or Legal Entity number, ID or Registration number and % of proceeds.

SECTION 6 PREMIUM

Name of bank account holder?

ID number or Registration number of account holder

If applicable, name of the designated signatory in the case of a legal entity or trust

If applicable, position of designated Signatory

Contact Number

Bank Name

Account Number

Account Type

Cheque

Savings

Transmission

Branch

Branch Code

SECTION 7 STARTING DATE

Would you have a preferred starting date for this policy or just as soon as possible? *

I want the policy to start on a specific date

Just start the policy as soon as possible

When you you want the policy to start?

Note: Policies can only start on the first of a month

I Declare and guarantee that the information is true, complete and precise.

SUDAC Life Cover Quote Form

SUDAC Online Life Insurance Quote form

The form takes just three minutes on average to complete for all the sections below.

Once you submitted it the data will go straight to Triarc and they will send you a quote in minutes!

SECTION 1

INSURED LIFE

SECTION 2

POLICY OWNER

A. OCCUPATION

TELL US WHAT YOU ARE INTERESTED IN

Choose the Cover you are interested in below.

DEATH COVER REQUIREMENTS

DISABILITY OR FUNCTIONAL IMPAIRMENT COVER REQUIREMENTS

DREAD DISEASE REQUIREMENT

INCOME PROTECTION REQUIREMENTS

B. FOREIGN TRAVEL

C. AVOCATION

D. INSURANCE HISTORY

E. HABITS, MEASUREMENTS AND FAMILY HISTORY

F. DOCTORS/SPECIALISTS/HEALTHCARE PROVIDER(S)

G. YOUR MEDICAL HISTORY

H. MEDICAL TESTS

SECTION 4

ADDITIONAL QUESTIONS FOR INCOME PROTECTION BENEFITS

SECTION 5

BENEFICIARY

SECTION 6

PREMIUM

SECTION 7

STARTING DATE

About Us

About us

Contacts