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Case Study 4
 

This Case study survey has been compilled for Charl du plooy at Curemed and should be completed by His clients.

 
   
 

CLIENT:

   
  Please complete the fields below:
     
  Name & Surname:
  Marital status:
  Marital contract:
  Date of Birth:
  Identity Number:
  Occupation:
  Highest qualification:
  Gross Monthly income:
  Smoker (Yes/No):
  Home Language:
     
   
 

SPOUSE:

   
  Please complete the fields below:
     
  Name & Surname:
  Date of Birth:
  Identity Number:
  Occupation:
  Highest Qualification:
  Gross Monthly Income:
  Smoker (Yes/No):
  Home Language:
 
     
  Please complete the fields below:
     
  Do You or Your Spouse participate in any Hazardous activities (Yes/No):
  If Yes please Specify:
     
   
 

Discovery Health & Vitality Details:

   
  The Client has the following Plan:
     
  1.
  2.
  3.
     
   
 

CHILD 1:

   
  Please complete the fields below:
     
  Name & Surname:
  Date of Birth:
  ID Number:
  Gender:
     
   
 

CHILD 2:

   
  Please complete the fields below:
     
  Name & Surname:
  Date of Birth:
  ID Number:
  Gender:
     
   
 

CHILD 3:

   
  Please complete the fields below:
     
  Name & Surname:
  Date of Birth:
  ID Number:
  Gender:
     
   
 

CHILD 4:

   
  Please complete the fields below:
     
  Name & Surname:
  Date of Birth:
  ID Number:
  Gender:
     
   
 

ADDRESS & CONTACT DETAILS:

   
  Please complete the fields below:
     
  Contact Person:
  Physical Address:
  Postal Address:
  Home Telephone:
  Work Telephone:
  Fax Number:
  Cell Phone:
  Email Address:
     
   
 

BANK DETAILS:

   
  Please complete the fields below:
     
  Account Holder Name:
  Bank Name:
  Branch:
  Branch Code:
  Account Number:
  Account Type:
     
   
 

INSURANCE POLICIES - MAIN MEMBER:

   
  Main member Name & Surname:
 
   
  Contract Type:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Contract Number:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Product Category:
 
Old Mutual:Sanlam:Momentum Wealth
     
  DOC:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Cease date / Maturity date:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Premium:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Premium Frequency:
 
Old Mutual:Sanlam:Momentum Wealth
     
  ACI:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Premium Increase Type:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Cash Value:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Surrender Value:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Maturity Value:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Main Life Assured:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Policy Owner:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Beneficiaries:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Benefits - Life Cover:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Benefits - ICB:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Benefits - SIB:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Funds - fund type:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Funds - fund name:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Funds - number of units:
 
Old Mutual:Sanlam:Momentum Wealth
     
  Funds - sell price
 
Old Mutual:Sanlam:Momentum Wealth
     
   
 

ASSETS AND LIABILITIES - MAIN MEMBER:

   
  Main member Name & Surname:
 
   
  Purchase Date:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  Market Value:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  Liability Amount:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  Purchase Value + Cost of Improvement after 1 Ocktober 2001:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  Invetment Growth:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  % Used for Business:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  Live Cover Bequeathed to Spouse:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  Life Cover Bequeathed to PBO:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  Life Cover Realised on Death:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  Realised on Disability:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  Liability @ Retirement:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  % to fund retirement income:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  % to fund retirement capital:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  % of liability to settle on retirement:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
  % of liability not settled on retirement:
 
Primary Residence:Vehicle:Holiday Flat:Bank Debt: Overdraft:
     
   
 

ASSETS AND LIABILITIES FOR SPOUSE:

   
  Spouse Name & Surname:
 
   
  Purchase Date:
 
Property (Flat):Vehicle:
     
  Market Value:
 
Property (Flat):Vehicle:
     
  Liability Amount:
 
Property (Flat):Vehicle:
     
  Purchase Value + Cost of Improvement after 1 October 2001:
 
Property (Flat):Vehicle:
     
  Investment Growth:
 
Property (Flat):Vehicle:
     
  % Used for Business:
 
Property (Flat):Vehicle:
     
  Life Cover - Bequeathed to Spouse:
 
Property (Flat):Vehicle:
     
  Life Cover - Bequeathed to PBO:
 
Property (Flat):Vehicle:
     
  Life Cover - Realised on Death:
 
Property (Flat):Vehicle:
     
  Realised on Disability:
 
Property (Flat):Vehicle:
     
  Liability @ Retirement:
 
Property (Flat):Vehicle:
     
  % to fund retirement income:
 
Property (Flat):Vehicle:
     
  % to fund retirement capital:
 
Property (Flat):Vehicle:
     
  % of liability to settle on retirement:
 
Property (Flat):Vehicle:
     
  % of liability not settled on retirement:
 
Property (Flat):Vehicle:
     
   
 

INFORMATION ABOUT CLIENT NEEDS:

   
  GENERAL:
   
 
   
  LIFE COVER:
   
 
   
  DISABILITY COVER:
   
 
   
  RETIREMENT:
   
 
   
 


 
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