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10
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1
Name
*
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First Name
Last Name
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2
Phone Number
*
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3
Email
*
This field is required.
example@example.com
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4
Which service do you require?
*
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Insurance - Long Term
Investments
Wills & Testaments
Insurance - Long Term
Investments
Wills & Testaments
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5
Insurance - Long Term
*
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Life Cover
Disability Income (Temporary or Permanent)
Permanent Disability Lump Sum
Severe Illness Lump Sum
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6
Life Cover
*
This field is required.
How much life cover do you need?
R100,000 - R500,000
R501,000 - R1,000,000
R1,001,000 - R2,000,000
R2,001,000 - R3,000,000
R3,001,000 - R5,000,000
R5,001,000+
R100,000 - R500,000
R501,000 - R1,000,000
R1,001,000 - R2,000,000
R2,001,000 - R3,000,000
R3,001,000 - R5,000,000
R5,001,000+
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7
Disability Income (Temporary or Permanent)
*
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What amount of monthly income do you need to cover life expenses if you become disabled?
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8
Permanent Disability Lump Sum
*
This field is required.
What amount do you need to pay off debt and cover additional expenses if disabled?
R100,000 - R500,000
R501,000 - R1,000,000
R1,001,000 - R2,000,000
R2,001,000 - R3,000,000
R3,001,000 - R5,000,000
R5,001,000+
R100,000 - R500,000
R501,000 - R1,000,000
R1,001,000 - R2,000,000
R2,001,000 - R3,000,000
R3,001,000 - R5,000,000
R5,001,000+
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9
Severe Illness Lump Sum
*
This field is required.
Diagnosed with a severe illness but not disabled (Eg. Cancer) yet? What amount should pay out to help with your substantially more expenses life?
R100,000 - R500,000
R501,000 - R1,000,000
R1,001,000 - R2,000,000
R2,001,000 - R3,000,000
R3,001,000 - R5,000,000
R5,001,000+
R100,000 - R500,000
R501,000 - R1,000,000
R1,001,000 - R2,000,000
R2,001,000 - R3,000,000
R3,001,000 - R5,000,000
R5,001,000+
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10
Investments
*
This field is required.
Which investment options are you interested in?
Retirement Annuity
Pension/Provident Preservation Fund
Tax-Free Savings Account
Education Plan
5 Year Endowment
Unit Trust
Retirement Annuity
Pension/Provident Preservation Fund
Tax-Free Savings Account
Education Plan
5 Year Endowment
Unit Trust
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11
Retirement Annuity - Retire Age
*
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At what age do you want to retire?
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12
Retirement Annuity - Investment Frequency
*
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Do you want to invest on a monthly basis, make a single contribution or both?
Monthly
Single Contribution
Both
Monthly
Single Contribution
Both
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13
Retirement Annuity - Monthly
*
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How much do you want to invest monthly towards your retirement?
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14
Retirement Annuity - Single Investment
*
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How much do you want to contribute as a single investment towards your retirement?
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15
Retirement Annuity - Risk
*
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Consider what risk you are able to afford and are capable of managing emotionally (investment fluctuations over the next 3 years)
Low
Moderately Low
Moderate
Moderately Aggressive
Aggressive
Low
Moderately Low
Moderate
Moderately Aggressive
Aggressive
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16
Pension/Provident Preservation Fund - Yes/No
*
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Did you retire, get retrenched or resigned and want to reinvest your pension/provident fund?
YES
NO
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17
Pension/Provident Preservation Fund - Amount
*
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What amount is currently invested in your pension/provident fund?
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18
Tax-Free Savings Account
*
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How long do you want to invest?
Answer in months
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19
Tax-Free Savings Account
*
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How much do you want to save per month?
No more than R2750/Month
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20
Education Plan
*
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How many children do you have?
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21
Education Plan
*
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How many years before the first child goes to university?
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22
Education Plan
*
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What is your monthly budget towards saving for your child/children's education?
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23
5 Year Endowment - Investment Frequency
*
This field is required.
Do you want to invest on a monthly basis, make a single contribution or both?
Monthly
Single Contribution
Both
Monthly
Single Contribution
Both
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24
5 Year Endowment - Monthly
*
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How much do you want to invest monthly?
Minimum 5 years
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25
5 Year Endowment - Single Investment
*
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How much do you want to contribute as a single investment?
Minimum 5 years
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26
Unit Trust - Investment Frequency
*
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Do you want to invest on a monthly basis, make a single contribution or both?
Monthly
Single Contribution
Both
Monthly
Single Contribution
Both
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27
Unit Trust - Monthly
*
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How much do you want to invest monthly?
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28
Unit Trust - Single Investment
*
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How much do you want to contribute as a single investment?
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29
Unit Trust - Investment Term
*
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How long do you want to invest for?
Measured in years
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30
Will & Testaments
*
This field is required.
Make sure you that your final will and testament is written down, signed, captured and kept at a safe location. This will ensure that your family does not wait unnecessarily for your legacy to be passed to them. Capital Legacy specialises in exactly this service. Select this option and expect a call to set up a meeting and draft your will.
I understand.
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31
Income Before Deductions
*
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Please be as specific as you can.
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32
Highest Qualification
*
This field is required.
No Matric
Matric
+3 Year Diploma
Degree
Post-Graduate Degree
No Matric
Matric
+3 Year Diploma
Degree
Post-Graduate Degree
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33
Do you smoke?
*
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YES
NO
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34
Job Title
*
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35
Age
*
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36
Do you have medical aid?
*
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YES
NO
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37
Are you with any of the following medical aid groups?
*
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Discovery
Momentum
Not Listed
Discovery
Momentum
Not Listed
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38
Do you have Vitality?
*
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YES
NO
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39
Do you have Multiply?
*
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YES
NO
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