Consultant: Wynand Louw
Date: 14 May 2025

GAP COVER – INFO GATHERING & NEEDS ANALYSIS

Title
Initials
Surname*
ID / Passport Number*
Date of Birth*
Email*
Mobile
Work
Marital Status
Gender
Nationality
Citizenship
Residential Address
Postal Address
Employer
Occupation
Gross Salary R
Subsidy R
Source of Income
Source of Wealth
Number of Dependants Adults Spouse Children
Age of Dependants Adults Spouse Children
Current Medical Scheme

Review medical scheme and option

*Complete medical scheme needs analysis and record of advice
Level of hospital rate of reimbursement
Chronic Conditions

Choose Conditions

Medication
Other Medical Conditions
Need Need Identfied Comments or Details
Yes No
Cover for use of a non-network or designated provider
Co-payment and deductible cover
Cancer gap cover
Dreaded disease cover
Premium Waiver
Affordable Premium
Casualty Ward Cover
Prescribed Minimum Benefit (PMB) Cover
Gap Cover Benefit %

[Indicate whether a new gap cover is recommended or an existing policy is to be replaced]

See comparison attached Yes No
New Gap Cover
Replace Existing Policy
Broker Appointment
Preferred Communication
Consent to receive the following. Newsletters Product and industry-related updates
Information about complementary services and products Further processing of personal information, for example, quality assurance.