Julian Quote Form

PERSONAL DETAILS (1min)

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

PRODUCT SELECTION (10sec)

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

PRODUCT TWEAKING (1- 4 min)

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

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

LAST STRETCH (<1min)

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

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

Julian Quote Form

Thank you for your interest, now let's get your quote started!

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

Once you submitted it the data will come straight to me and then the fun starts!

Remember, if you prefer to do this via a phone call, just shout! I will call you back.

PERSONAL DETAILS (1min)

PRODUCT SELECTION (10sec)

TELL US WHAT YOU ARE INTERESTED IN

Choose the Cover you are interested in below.

PRODUCT TWEAKING (1- 4 min)

DEATH COVER REQUIREMENTS

DISABILITY OR FUNCTIONAL IMPAIRMENT COVER REQUIREMENTS

CRITICAL ILLNESS REQUIREMENTS

INCOME PROTECTION REQUIREMENTS

LAST STRETCH (<1min)

About Us

About us

Contacts