Consultant: Wynand Louw
Date: 21 May 2025

MEDICAL SCHEME – 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
Level of Hospital Cover
Hospital Preference
Chronic Conditions

Choose Conditions

Medication
Other Medical Conditions
Day-to-day Cover
Current Medical Scheme
From
To
Any period that you have not been part of a Medical Scheme?
Is anyone within the family currently pregnant?
Amount budgeted in terms of monthly Medical Scheme premiums R
Any planned procedures (e.g. knee operation, orthodontic treatment, pregnancy, etc.)
Need Need Identfied Comments or Details
Yes No
Hospital Cover
Day-to-Day Benefit
Threshold Benefit
Chronic Benefit
Savings Account
Affordable Premium
Hospital Preference
Gap Cover

If Yes, Complete Gap Cover Needs Analysis & ROA
Other

[Indicate whether a new medical scheme(s) is recommended or an existing scheme is to be replaced]

See comparison attached Yes No
New Medical Scheme
Replace Medical Scheme
Broker Appointment
Plan Change
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.