Critical Insurance and Disability Questionnaire | Le'risque Africa
Critical Illness Cover pays out a lump sum when you get diagnosed with a severe illness like a cancer, stroke, coma, heart attack because medical cover is not usually enough: 

Disability Cover pays out a lump sum when you get a disability due to accident.

It is important because it helps with:

  • Income Replacement.

  • Medical Treatment Costs:

  • Living Expenses: 

  • Home Modifications.

  • Peace of Mind: 

This form is to highlight your knowledge and need for critical illness and disability insurance. This will guide us in preparing for the discovery call.

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Email *
Name:  *
Gender:

 *
Date of Birth: *
Occupation: *
Marital status: *
What is your smoking status? *
What income replacement covers do you want? *
Required
Do you want a stand alone critical illness/disability cover or as part of a life cover? *
Do you have any critical illness benefits in your protection portfolio? *
What is your overall knowledge of Critical illness and Disability insurance? *
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)?  *
Term of Protection of cover? (how long do you need to protect your income) - maximum is up to 65 years *
What is your preferred mode of communication? *
If you prefer a phone call, please share your phone number here
How did you hear about us? *
Comments and/or questions that can help us better prepare for our meeting 
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