Elementor #715

















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Client Quotation Request And Personal Information Form

Static Details















Quotation Details






Existing Cover at Other Life Insurance Companies (Excluding Sanlam)


Statement of health by life insured


Legislation requires a life insured to honestly and fully disclose all information which will help the underwriter decide
whether to accept the application and, if so, with which terms and payments. This disclosure from the life insured is
necessary because the life insured knows more about the risk to be insured than the underwriter.

Usually, with more information we can offer you better rates.


Most people would answer yes to one or more of the following questions. Which ones apply to you?







Please give further details of questions 5 to 11 if answered “Yes” above:

<6 Months>6 Months2 Years>2 Years5 Years>5 Years





<6 Months>6 Months2 Years>2 Years5 Years>5 Years





<6 Months>6 Months2 Years>2 Years5 Years>5 Years





<6 Months>6 Months2 Years>2 Years5 Years>5 Years





<6 Months>6 Months2 Years>2 Years5 Years>5 Years





<6 Months>6 Months2 Years>2 Years5 Years>5 Years





<6 Months>6 Months2 Years>2 Years5 Years>5 Years







Age of Cancer(s):





Age of Cancer(s):





Age of Cancer(s):





Age of Cancer(s):





Age of Cancer(s):





Age of Cancer(s):



Notes: This Statement of Health will be validated by the required signature(s) below.

Family doctors / Clinic

Who is your regular treating doctor or clinic?


Consent to Cansa


Notes: By signing here the life insured confirms the Statement of Health and also confirms particulars with
regard to him/her, contained elsewhere in this Statement of Health.