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Life Insurance Questionnaire 2024
Subject
*
Email
*
Name
*
Gender:
*
Female
Male
Date of Birth
*
Occupation:
*
My income is:
*
Regular (I have a salary, business has consistent income etc)
Irregular (I am in freelancing, starting out in business, between jobs etc)
Other
Other
*
Marital status:
*
Single
Married
Domestic Partnership
Divorced
Widowed
What is your smoking status?
*
Smoker (cigarette, e-cigarette, vape, any tobacco use)
Non smoker
What is your overall knowledge of life insurance?
*
Really good
Somewhere in the middle
No knowledge at all
Why is it important to get your life cover today?
*
To protect my family and income against unforeseen serious illness, death, disability only
To protect my family as above and leave an inheritance
Other
Other
*
Do you have any form of life cover?
*
Yes, Group Life (through work)
Yes, Personal Life
No
How many dependants do you have and their ages?
*
(A dependant is anyone depending on your income, could be spouse, children, parents)?
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)?
*
Learn More
HERE
Term of Protection of cover? (how long do you need to protect your income)
*
10 years
15 years
20 years
Upto 65
Other
Other
Your preferred frequency of payment? *Please note that paying lump sums comes with discounts with annual payment having the biggest discount*
*
Monthly
Quarterly
Semi-Annually
Annually
How soon do you want your life cover?
*
Immediately - Within the next month
Somewhat soon - In 3 - 6 months
Not anytime soon - 6 month + ( I'm just shopping around)
Other
Other
*
Are you interested in setting up a TRUST FUND for your beneficiaries?
*
Yes
No
Learn More
HERE
What is your preferred mode of communication?
*
Email
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
Susan Wanjiku, Legacy Hub
Just Ivy
Other
Other:
Submit