Refer

Title
—Please choose an option—MrsMrMissDrAdvJudgProf

Name

Surname

ID Number

Mobile Number

Email

Smoker Status
—Please choose an option—SmokerNon-smoker

Marital Status
—Please choose an option—SingleMarriedDivorcedSeparatedWidowed

Your Education
—Please choose an option—Less Than MatricMatric3-Year Diploma3-Year Degree/4-Year Diploma4-Year degree/Professional

Monthly Income (Gross)

Occupation

Must we quote on life cover?
—Please choose an option—YesNo

Must we quote on funeral cover?
—Please choose an option—YesNo

Have you ever been prescribed or have taken medication or treatment for Diabetes, Heart, High Blood Pressure etc. —Please choose an option—YesNo

Have you been diagnosed with cancer? —Please choose an option—YesNo

Have you been admitted to hospital for more than 3 days in the last 3 years other than for accidental injuries? —Please choose an option—YesNo

Are you considering consulting any medical doctor (including specialists) in the near future, or are you awaiting the results from tests or investigations done recently? —Please choose an option—YesNo

Are you comfortable answering about your HIV status? —Please choose an option—YesNo

What is your HIV status? —Please choose an option—YesNo