Note: The Client Personal Information Form will be forwarded to Alpha Cube Capital (Pty) Ltd to (a) prepare a My Cancer Cover Quotation for the client’s consideration or (b) initiate the application process for My Cancer Cover. All personal information is held securely in accordance with the appropriate legislation, confidential and treated appropriately.


CLIENT QUOTATION REQUEST AND PERSONAL INFORMATION FORM



MALEFEMALE

SingleDivorcedWidowedMarried in community of propertyMarried out of community of property with A.N.CMarried out of community of property without A.N.C


AFRIKAANSENGLISH

YESNO

BANK DETAILS


CHEQUESAVINGSTRANSMISSION

QUOTATION DETAILS

No Grade 12/MatricGrade 12/Matric3 Year Diploma3 Year Degree/B-Tech Degree/4 Year Diploma4 Year Degree & Higher






YESNO
R100 000R200 000R300 000R400 000R500 000

EXISTING COVER AT OTHER LIFE INSURANCE COMPANIES (EXCLUDING SANLAM)


CONSENT TO CANSA
YESNO

YESNO

Important! Please attach a copy of the ID / ID Card (front and back) for all applicable insured lives and premium payers (if the insured life and premium payer are different persons).

By clicking the box next to the Terms and Conditions below, the Client confirms and acknowledges that:

  1. The Client Quotation Request and Personal Information Form will be forwarded to Alpha Cube Capital (Pty) Ltd in order to:
  2. a. Prepare an initial My Cancer Cover Quotation for his/her, or any other designated party’s, consideration; and
    b. Initiate the application process for My Cancer Cover after acceptance of the said My Cancer Cover Quotation.

    Alpha Cube Capital (Pty) Ltd confirms that all personal information of the Client is held securely in accordance with the appropriate legislation, confidential and treated appropriately.

  3. The Client confirms the particulars with regard to him/her as provided in the Client Quotation Request & Personal Information Form and declares that the information provided herein is correct in every aspect.
  4. The Client agrees that all the necessary compliance procedures have been met as required by legislation, and that he/she is fully aware of his/her rights.
  5. It replaces the need for his/her personal signature hereto and is hereby regarded as if the Client has signed the Client Quotation Request and Personal Information Form in person.
I accept the Terms and Conditions above