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).
I Accept Terms and Conditions