Online Quote Form
Facebook
Twitter
LinkedIn
YouTube
Home
Life Insurance
Life Insurance All
Life Cover
Disability Cover
Functional Impairment Cover
Dread Disease Cover
Income Protection
HIV Life Insurance
Life Insurance Quote Form
Employee Benefits
About Triarc
Funeral Cover
Contact
Individual Risk Claims
Group Risk Claims
More
Update My Information
Feedback
FAQ
Blog
WELCOME TO
TRIARC
, A
PIONEERING
LIFE INSURANCE PROVIDER FOR ALL
PROGRESSIVE
SOUTH AFRICANS
0
Already support Triarc
GET A CALL
Talk to a Financial Advisor
GET A QUOTE
3min Online Quote Form
If you are human, leave this field blank.
Would you rather continue this on your Desktop PC?
Enter your desktop PC email address so we can send you a link
Submit
SUBMIT YOUR DETAILS TO GET A CALL FROM A FINANCIAL ADVISOR
If you are human, leave this field blank.
Full Name
*
Phone Number
Email Address
Submit
GET A QUOTE NOW
If you are human, leave this field blank.
Complete this form to get your quote now
First Name:
*
Surname:
*
ID or Passport Number:
*
Are you a permanent resident in South Africa?
*
Yes
No
Gender
*
Male
Female
Telephone Number
*
Email Address
*
Occupation Name:
*
The Industry you work in:
*
Type of work you do:
*
What kind of work do you do on a typical day?
Highest Qualification
*
Less than Matric
Matric
3 Year Diploma or 3 Year Degree
4 Year Degree or greater
Relationship Status
*
Single
Married
In a relationship
How long have you been together?
*
Your Gross Monthly income:
*
Your Gross Household income:
*
For you and your partner put together.
Are you a smoker?
*
Yes
No
TELL US WHAT YOU ARE INTERESTED IN
What do you need the cover for?
*
Select 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
Critical Illness 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
*
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
*
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
*
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
For how long do you need Death Cover?
*
My whole life
5 Years only
10 Years only
15 Years only
20 Years only
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
CRITICAL ILLNESS REQUIREMENTS
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 R20,000)
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)
*
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 question, but relates to the cover increasing while you are getting Income Protection payouts due to a claim.
0% Annual Increase
5% 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 your last 3 recorded CD4 counts?
*
Most recent first please.
What was the date of your last recorded 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
Please indicate if you had any of the following diseases or symptoms:
*
TB
Pneumonia
Kaposi Sarcoma
Recurring Fungal Infections
Extreme loss of weight
Loss of memory
Confusion
Passing out
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
Submit
