Tell Us About You

All information is kept in strict confidence and is used to determine your personal needs and requirements, so that we can provide you with a personalised financial plan.

Full Name

First Name Middle Name Last Name

Birth Date

Month Day Year

Work Phone Number

Area Code Phone Number

Mobile Number

E-mail

Qualifications

Occupation

Are you married

Yes No

What is your maiden name

Dependants

	Name	Surname	Date of birth	Gender
Child 1
Child 2
Child 3
Child 4

Do you smoke

Yes No

Do you know your HIV status

Yes No

Do you have Diabetes

Yes No

Have you been treated for Diabetes

Yes No

Percentage of daily duties (please indicate the percentage spent on these duties daily)

	Percentage
Admin
Supervision
Travel
Manual

Personal Financial Planning Requirements

What is your gross monthly income (please send us a copy of a recent payslip)

Assets and Liabilities (for Estate Planning purposes)

	Current Value	Debt amount (How much do you owe)	Year bought (base year)	Original Purchase price
Property
Property
Property
Vehicle
Vehicle
Business Interest
Business Interest
Other
Other

Which Medical Aid are you on

Are you on Vitality?

Yes No

Do you have a will?

Yes No

Please add any additional comments or questions:

Group Life Benefits (Employee Benefits)

If you know what your employee benefit amounts are, please fill them in below. Alternatively, please send us a copy of your recent Pension / Provident Fund statement which reflects the current fund value. Also, please send us a statement reflecting an explanation of what Group Life benefits you have (Income Disability benefits, Life cover, Lump Sum Disability cover and Dreaded Disease benefits)

Do you belong to a Pension or Provident Fund at work

Do you have Group Life benefits (Employee benefits eg Life cover and / or Disability Income benefits) at work

Yes No

Current Fund value of Pension / Provident Fund

(We use this value to incorporate into your Retirement Planning figures)

If you have Life cover at work, please mention how much cover you have eg 1,000,000 or 0

If you have Lump Sum Disability cover at work, please mention how much you have eg. 1,000,000 or 0

If you have Income Disability benefits at work, please indicate benefit amount, waiting period and benefit expiry age

	Monthly Benefit	Waiting period	Benefit expiry age
Income Disability Benefit

If you have Dreaded Disease benefits at work, please mention how much you have eg. 1,000,000 or 0

Personal Requirements

In the event of death, would you like to make provision for a lump sum for a specific reason eg enough funds for your spouse to buy a house etc

	Amount	Reason (eg buy house)
Item 1
Item 2
Item 3
Item 4
Item 5

In the event of death, would you like leave an income for your spouse and / or children or somebody else

	Income per month (today's value)	Years that income must last
Spouse
Child 1
Child 2
Child 3
Other

What age would you like to retire

How much would you like to retire on per month (in today's value)

Would you like to plan for your children's education? If so, please indicate your preferences by typing "yes"or "no" or the name of the institution where applicable

	Public School	Private School	Preferred School (Name of School)	Residency (if applicable)
Primary School
Secondary School
University

Do you have any investment objectives? Please elaborate

General comments

FINANCIAL PLANNING ANALYSIS QUESTIONNAIRE