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Life Insurance Quote Form
Complete the Quote form below or if you prefer a
phone call,
submit your contact details and we will call you right back.
HAVE A QUESTION? LET US CALL YOU BACK!
If you are human, leave this field blank.
Full Name
*
Phone Number
Email Address
Submit
GET YOUR QUOTE WITH THE QUOTE FORM BELOW
If you are human, leave this field blank.
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.
For how long do you need Death Cover?
*
Yes
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
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?
*
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.
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 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
Not Applicable
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
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?
*
Why did your weight change in the last year?
*
Exercise
Diet
Pregnancy
Illness / Medical condition
Other
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
Please tick all that apply
*
High Blood Pressure Treatment
Heart attack
Stroke
Ischaemic Heart Disease
Raised Cholesterol
Heart murmur
Any cardiac procedure
Palpitations
Rheumatic fever
Angina
Other
Do you, or have you ever suffered from Respiratory and/ or Lung problems?
*
Yes
No
Tick all that apply
*
Asthma
Chronic Bronchitis
Tuberculosis or other lung infections
Emphysema or obstructive airways
Persistent coughing
Interstitial lung disease
Other
Do you, or have you ever suffered from Digestive system, gall bladder, pancreas or liver problems?
*
Yes
No
Tick all that apply
*
Hepatitis A or Jaundice
Gall bladder problems
Liver disease
Rectal bleeding
Hernia
Stomach ulcers
Abnormal liver function
Pancreatitis
Other
Do you, or have you ever suffered from Kidneys, Bladder or Reproductive organ problems?
*
Yes
No
Tick all that apply
*
Protein or blood in the urine
Problems with the uterus
Kidney stones
Bladder infection
Prostate problems
kidneys disease
Other
Do you, or have you ever suffered from Central Nervous System or Mental Health Problems?
*
Yes
No
Tick all that applies
*
Psychiatrist/psychologist consultation
Paraplegia, quadraplegia, loss of use limb
Persistent migraine or headache
Depression, stress or anxiety
Epilepsy, fits or blackouts
Brain disorders
Multiple sclerosis
Alzheimers disease
Parkinsons disease
other
Do you, or have you ever suffered from Spine, joints, bones,muscles, limbs or skin problems
*
Yes
No
Please tick all that apply
*
Back ache, slipped disc or spinal surgery
Joint problems/ joint replacement
Dermatitis/Psoriasis/Eczema
Fractured/broken bones
Rheumstism/Fibromayalgia
Any muscular problems
Gout
Arthritis
Other skin troubles
Other spine, joints, bone, muscle, limb problems
Do you, or have you ever suffered from Ear, Nose, Throat and Eye, problems?
*
Yes
No
Tick all that apply
*
Problems with tongue and salivary glands
Haorseness or loss of voice
Defective vision
Problems with nose
Glaucoma
Hearing loss
Continuous high pitch ringing in your ears
Other
Do you, or have you ever suffered from Diabetes, glandular, blood or hormonal disorders?
*
Yes
No
Tick all that apply
*
Bleeding disorders
Diabetes
Metabolic syndrome
Anaemia
Glandular disorder
Thyriod problems
Insulin resistance
Other
Do you, or have you ever suffered from Any from of malignant cancer, growth or tumour/ removed or existing?
*
Yes
No
Tick all that apply
*
Skin
Liver
Prostate
Breast
Lung
Uterus/Cervix
Bowel
Brain
Other
Do you, or have you ever suffered from any form of benign cancer, growth or tumour/removed or existing
*
Yes
No
Tick all that apply
*
Sun spots/solar ketatosis
Lumps/cysts in breast
Moles or lumps
Fibroadenoma
Cysts
Other
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
Tick all that applies
*
ECG
Angiograms
Scopes
Scans
Tumour markers
X-Rays
Genetic testing
Have you or are you in the process of having gender reassignment?
*
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
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.
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
Will this policy be ceded?
Yes
No
If Yes, please also ensure that you supply Triarc with a copy of the Cession form
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
Premium Deduction Date
1
7
15
25
26
27
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.
I Agree and SUBMIT
