Company Name * Surname * Contact Number * Email: * Life Cover Amount (N$100 000 minimum) * Dread Disease Cover Amount (N$100 000 minimum) * Disability Cover Amount (N$100 000 minimum) * Date of Birth (dd-mm-yyyy) * Age * Dread disease * Yes No Disability * Yes No Premium back Option * Yes No Qualification * 4 Year degree 3 Year degree Matric Grade 10 /std 8 Height (cm) * Weight (Kg) * Cholesterol - If unsure please select 6 * 0 1 2 3 4 5 6 7 8 9 10 Blood Pressure * 120-150 151-155 156-160 161-165 166-170 Smoker * Yes No AIDS * Yes No Liver Function * Low Normal High reCAPTCHA *