Needs Analysis Questionnaire

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Examination…   Diagnosis…   Prescription…

Answering the questions below is necessary to examine your needs, wishes, requirements and problems concerning your health care cover. On the basis of your answers, I shall make a diagnosis and give you my prescription as to what you must do. With clarity, sincerity and absence of hype, so that you can make an informed decision.

Please answer all the questions, in the blank spaces, giving full particulars. If something is not applicable, type N/A. When done, click Send at the bottom hereof.

The contributions of many options are based on monthly income. This provides an opportunity for lower income earners to obtain excellent cover at really affordable contributions per month. Therefore, the two questions below regarding gross income, if below R18 000 per month.

I treat all your information with the utmost professional secrecy.

Needs Analysis Questionnaire

Initials and Surname

Your email address

Cellphone (In format 000 000 0000)

Your preferred Name, Surname and Age

Spouse’s preferred Name, Surname and Age (if a beneficiary)

Child beneficiaries: Names, (S)Son/(D)Daughter, Ages

Have you, or any of your beneficiaries, during the past year:
Been hospitalised
Been diagnosed with any medical condition
Been treated for any medical condition
Been suffering from any chronic medical condition(s)
Consulted any medical service provider(s)
Females: currently pregnant or planning to get pregnant
Are you aware of any planned operation/treatment in the future

Furnish full details if you have answered “Yes” to any of these questions

Your current Scheme/option and contribution pm

Your spouses current Scheme/option and contribution pm (if different)

What problems do you experience with your current health care cover

Details of any applicable late joiner penalties and/or waiting periods

How long have you belonged to medical schemes since age 21

How long has your spouse belonged to medical schemes since age 21

Describe your ideal medical scheme which you would like to join

Details of your gap cover and other supplementary cover

What are your and your spouses academic qualifications

Maximum contribution you wish not to exceed pm

Is your contribution pm subsidized; if so, by how much

Your gross income pm (if less than R18 000 pm)

Your spouse’s gross income pm (if less than R18 000 pm)

Anything else you would like to mention or any questions now

Where or from whom did you hear of me

Always as near to you as the nearest phone or computer

heindeBruin_04_print_03 - KopstukB.Proc.  N.Dip.(Marketing)
Financial Services Provider — Lisence 8840
Health Care Broker — Accreditation BR 285
Accredited PPS Broker — B/Code 124314907

Language Editor Dr. Lariza Hoffman

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