Critical Insurance and Disability Questionnaire

This form is to highlight your knowledge and need for critical illness insurance. This will guide us in preparing for the discovery call.

Subject *

Email *

Name *

Gender: *

Female

Male

Date of birth *

Occupation:

Marital status: *

Single

Married

Domestic Partnership

Divorced

Widowed

What is your smoking status? *

Smoker (cigarette, e-cigarette, vape, any tobacco use)

Non smoker

What income replacement covers do you want? *

Critical Illness

Disability Insurance

Do you want a stand alone critical illness cover or as part of a life cover? *

Stand Alone

Part of a life cover (comes as an additional benefit to a life cover)

Do you have a family member who has ever been diagnosed with a critical illness? *

Yes - immediate family member

One can get a critical illness even if there has been no family history of the illness. But it is even more important for those who have family members with a history of cancer, stroke, kidney failure etc to have cover

Do you have any critical illness benefits in your protection portfolio? *

Yes - through personal cover(s)

What is your overall knowledge of critical illness insurance? *

Really good

Somewhere in the middle

No knowledge at all

What level of protection are you looking for (The sum assured) Or what is your monthly budget for your life cover (the premium you want to pay)? *

Term of Protection of cover? (how long do you need to protect your income) *

Maximum is up to 65 years

What is your preferred mode of communication? *

Phone call

Whatsapp/Message

Any of the above

Other

Other *

If you prefer a phone call, please share your phone number here

Comments and/or questions that can help us better prepare for our meeting

Where did you hear about us: *

@lerisqueafrica

thesoftlifespecialist

Agatha, The Wealth Tribe

Susan Wanjiku, Legacy Hub

Other

Submit

Nairobi • Kenya

+254 114102667
cx@lerisqueafrica.com