LIFE INSURANCE QUOTE Please enable JavaScript in your browser to complete this form.Name *FirstLastNumber *Email *Gender *GenderFemaleMaleOtherPrefer not to sayPermanent resident in South Africa *Permanent resident in South AfricaYesNoOccupation Name *The Industry you work in *Type of work you do *Highest Qualification *Highest QualificationLess than MatricMatric3 Year Diploma or 3 Year Degree4 Year Degree or greaterRelationship Status *Relationship StatusSingleMarriedIn a RelationshipWidow/WidowerHow long have you been together? *Your Gross Monthly Income *Gross Household Monthly Income *Are you a smoker *Are you a smokerYesNoWhat do you need cover for? *Providing for my family of someone specialProtecting your living standardDebt protectionEstate duty shortfallChoose the type of Cover *Death CoverDisability CoverCritical Illness CoverIncome ProtectionDeath Cover Requirements *Give me the premium for the cover amount below (example R1mil)Give me the highest cover for the premium amount below (example R200pm)Cover/Premium amount? *Premium Pattern *Level Premium PatternConservative Premium Pattern Aggressive Premium PatternThe main choice to make is do you always want to pay the exact premium related to your cover amount, called "Level premium" or do you want to pay a lower premium now to help your budget and increased premium in later years, called "Premium Pattern". Choose "Conservative" if you want a lower premium now and wouldn't mind paying more later, or "Aggressive" if you want the lowest possible premium now. (keep in mind the premium will increase significantly in later years)Cover Amount Increase *0% Annual Increase3% Annual Increase6% Annual IncreaseYou can choose to increase the Cover Amount by 3% or 6% annually, or leave it as it is now. (0%)Guarantee *Fix my premiumDon't fix my premiumYou have the option to fix your premium for a number of years, or allow the insurer to increase it if necessary based on their risk experience. Fixing your premium costs slightly more.For how long do you need Death Cover? *Whole life5 Years only10 Years only15 Years only20 Years onlyDisability Cover Requirements (FI) *Give me the premium for the cover amount below (example R1mil)Give me the highest cover for the premium amount below (example R200pm)Cover/Premium amount? *Premium Pattern (FI) *Level Premium PatternConservative Premium Pattern Aggressive Premium PatternThe main choice to make is do you always want to pay the exact premium related to your cover amount, called "Level premium" or do you want to pay a lower premium now to help your budget and increased premium in later years, called "Premium Pattern". Choose "Conservative" if you want a lower premium now and wouldn't mind paying more later, or "Aggressive" if you want the lowest possible premium now. (keep in mind the premium will increase significantly in later years)Cover Amount Increase (FI) *0% Annual Increase3% Annual Increase6% Annual IncreaseYou can choose to increase the Cover Amount by 3% or 6% annually, or leave it as it is now. (0%)Guarantee (FI) *Fix my premium for 5 yearsDon't fix my premiumYou have the option to fix your premium for a number of years, or allow the insurer to increase it if necessary based on their risk experience. Fixing your premium costs slightly more.Stand Alone or Accelerated? (FI) *Stand AloneAcceleratedChoose "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.To what age do you need this cover? (FI) *Critical Illness Requirements (CI) *Give me the premium for the cover amount below (example R1mil)Give me the highest cover for the premium amount below (example R200pm)Cover/Premium amount? *Premium Pattern (CI) *Level Premium PatternConservative Premium Pattern Aggressive Premium PatternThe main choice to make is do you always want to pay the exact premium related to your cover amount, called "Level premium" or do you want to pay a lower premium now to help your budget and increased premium in later years, called "Premium Pattern". Choose "Conservative" if you want a lower premium now and wouldn't mind paying more later, or "Aggressive" if you want the lowest possible premium now. (keep in mind the premium will increase significantly in later years)Cover Amount Increase (CI) *0% Annual Increase3% Annual Increase6% Annual IncreaseYou can choose to increase the Cover Amount by 3% or 6% annually, or leave it as it is now. (0%)Guarantee (CI) *Fix my premium for 5 yearsDon't fix my premiumYou have the option to fix your premium for a number of years, or allow the insurer to increase it if necessary based on their risk experience. Fixing your premium costs slightly more.Stand Alone or Accelerated? (CI) *Stand AloneAcceleratedChoose "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.To what age do you need this cover? (CI) *Income Protection Requirements (IP) *Give me the premium for the cover amount below (example R1mil)Give me the highest cover for the premium amount below (example R200pm)Cover/Premium amount? *Premium Pattern (IP) *Level Premium PatternConservative Premium Pattern Aggressive Premium PatternThe main choice to make is do you always want to pay the exact premium related to your cover amount, called "Level premium" or do you want to pay a lower premium now to help your budget and increased premium in later years, called "Premium Pattern". Choose "Conservative" if you want a lower premium now and wouldn't mind paying more later, or "Aggressive" if you want the lowest possible premium now. (keep in mind the premium will increase significantly in later years)Cover Amount Increase (IP) *0% Annual Increase3% Annual Increase6% Annual IncreaseYou can choose to increase the Cover Amount by 3% or 6% annually, or leave it as it is now. (0%)Guarantee (IP) *Fix my premium for 5 yearsDon't fix my premiumYou have the option to fix your premium for a number of years, or allow the insurer to increase it if necessary based on their risk experience. Fixing your premium costs slightly more.Stand Alone or Accelerated? (IP) *Stand AloneAcceleratedChoose "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.Deferred Period (IP) *1 Month3 Months6 Months12 MonthsThis is the time you have to wait after you became unable to earn an income before you can put in a claim.HIV status? *I don't knowI am HIV-I am HIV+CD4 count at date of diagnoses? *Privacy Policy *I agree to the Privacy PolicyBy submitting this form you agree to the terms of the Privacy Policy, which means we undertake to protect your personal data in compliance with the Protection of Personal Information Act.SUBMIT