Name Surname Email Contact Number Maximum Premium you can afford? Funeral Cover Funeral Cover R10 000 - R20 000 R21 000 - R30 000 R31 000 - R40 000 R41 000 - R50 000 Life Cover Life Cover R250 000 - R350 000 R351 000 - R450 000 R451 000 - R550 000 R551 000 - R650 000 R651 000 - R750 000 R751 000 - R850 000 R851 000 - R1 000 000 Are you currently a smoker? Yes No Do you drink alcohol ? Yes No Do you have any of the following disorders ? Do you have any Heart Condition Do you have Respiratory or lung trouble Do you have Stomach, Bowel, Pancreatic, Liver, Bladder, Kidney condition Are you on any medication to treat a condition Do you have Cancer, Leukaemia, Tumour or Growth Any major accidents or treatments not listed in the past 24 months Submit Don't have a plan? Book Appointment
